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Preferred Drug List (List of Covered Drugs)
This document includes Passport Health Plan’s complete 2016 formulary.
What is the Passport Health Plan formulary?
The formulary is a list of preferred drugs covered by Passport. To get a drug on our formulary, you must:
• BeaPassportmember;
• Needadrugthatismedicallynecessary;
• GettheprescriptionfilledataPassportHealthPlannetworkpharmacy.AnetworkpharmacyisonethatissignedupwithPassport;and
• FollowallPassportrules(seelimitsbelow).
The formulary is not a complete list of covered drugs by Passport. Some drugs not listed may be covered, if medically necessary. These drugs may or may not need prior-authorization.
How do I find my drug on the formulary?
• Youcansearchforadrugusingtheonlinesearchableformularyonourwebsiteatwww.passporthealthplan.com.
Are there any limits to the drugs you have been prescribed?
Some covered drugs may have limits on them. This could include:
• Prior-Authorization:SomemedicinesmustbeapprovedbyPassportbeforePassportwillcoverorpayforthem.Thismeansyourproviderwillneedtogetapprovalbeforeyoucanhaveyourprescriptionsfilled.Ifyoudonotgetapproval,Passportmaynot cover the drug.
• Quantity Limits:Forsomedrugs,therearelimitsontheamountPassportwillcover.Thismeansyoumaynotgetthestandard one month supply.
• Step Therapy:SometimesPassportrequiresyoutotrycertaindrugsfirsttotreatyourmedicalconditionbeforewewillcoveranotherdrugforthatcondition.Forexample,ifDrugAandDrugBbothtreatyourmedicalcondition,PassportmaynotcoverdrugBunlessyoutryDrugAfirst.IfDrugAdoesnotworkforyou,PassportwillthencoverDrugB.
• Too Early to Refill:Ifyouaregivenamonthsupplyofamedicine,Passportwillnotcoverarefilloftheprescriptionuntil30 days has passed.
What if my drug is not on the formulary?
Remember,notalldrugsarelistedontheformulary.IfPassportdoesnotcoveryourdrug,youhave3options:
1. Workwithyourpharmacyorprovidertofindthepreferreddrug.
2. YoucancallMemberServicesat1-800-578-0603andaskforalistofsimilardrugsthatareonPassport’sPreferredDrugList.
3. IfadrugisnotcoveredbyPassportorisnotlistedonourPreferredDrugList,yourdoctorcanrequestapprovalforit.
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Can the formulary change?
Yes.Passportmayaddorremovedrugsfromtheformularyduringtheyear.Togetupdatedinformationaboutcovereddrugs,pleasevisitourwebsiteatwww.passporthealthplan.comorcallMemberServicesat1-800-578-0603.
What are generic drugs?
Passportcoversbothbrand-nameandgenericdrugs.Agenericdrughasthesameactiveingredientasthebrand-namedrug.Thismeanstheyworkthesameandhavethesameeffect.GenericdrugsusuallycostlessthanbrandnamedrugsandareapprovedbytheFoodandDrugAdministration(FDA).
How much are my copays?
Aslongasyoutakegenericmedicines,youwillpay$0.Ifyoutakeapreferredbrandnamemedicine,yourcopaywillbe$2.Ifyoutakeanon-preferrednamebrandmedicine,yourcopaywillbe$4.
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LEGEND
TYPE DESCRIPTION
QL Quantity LimitThere is a limit on the amount of this drug that is covered perprescription, or within a specific time frame.
PA Prior AuthorizationYour provider is required to get prior authorization before you fill yourprescription, which ensures appropriate use of the selected drug.Without prior approval, we may not cover this drug.
ST Step TherapyIn some cases, you may be required to first try certain drugs to treatyour medical condition before you move up a “step” to other drugoptions.
GL Gender Limit This prescription drug is restricted for a single gender. .
AL Age LimitThis prescription drug may only be covered if you meet the minimumor maximum age limit.
C Custom This drug has unique restrictions.
S Specialty DrugSpecialty drugs are high-cost drugs used to treat complex or rareconditions. Some examples of the diseases include; multiple sclerosis,rheumatoid arthritis, hepatitis C, and hemophilia.
MED Medical DrugThis medication is not on our drug list. Click on the THERAPEUTICCLASS or sub class to find covered alternative medications. If youhave questions, please contact member services.
PAGE 4 LAST UPDATED 02/2016
LIST OF COVERED PRESCRIPTION MEDICATIONS DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
ANALGESICS
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
CELEBREX 50 MG CAPSULEcelecoxib
BRAND PA
choline sal/mag salicylate 500 mg/5ml liquid generic
diclofenac potassium 50 mg tablet generic
DICLOFENAC SODIUM (50 MG TABLET DR, 100 MGTAB ER 24H, 25 MG TABLET DR, 75 MG TABLET DR)
generic
DICLOFENAC SODIUM/MISOPROSTOL (50 IR, 75 IR) genericQL
PA
diflunisal 500 mg tablet generic
ETODOLAC (200 MG CAPSULE, 400 MG TAB ER 24H,400 MG TABLET, 300 MG CAPSULE, 500 MG TABLET,500 MG TAB ER 24H, 600 MG TAB ER 24H)
generic
FENOPROFEN CALCIUM (400 MG CAPSULE, 600 MGTABLET)
generic
FLURBIPROFEN (50 MG, 100 MG) generic
IBUPROFEN (400 MG, 600 MG, 800 MG) generic
INDOMETHACIN (25 MG, 75 MG ER, 50 MG) generic
indomethacin sodium 1 mg vial generic
KETOPROFEN (75 MG CAPSULE, 50 MG CAPSULE, 200MG CAP24H PEL)
generic
KETOROLAC TROMETHAMINE (15 MG/ML VIAL,30MG/ML(1) VIAL, 30 MG/ML CARTRIDGE, 10 MGTABLET, 30 MG/ML VIAL, 15 MG/ML CARTRIDGE, 60MG/2 ML VIAL, 60 MG/2 ML SYRINGE)
generic
MECLOFENAMATE SODIUM (50 MG, 100 MG) generic
mefenamic acid 250 mg capsule generic
MELOXICAM (7.5 MG TABLET, 7.5 MG/5ML ORALSUSP)
generic
meloxicam 15 mg tablet generic GL Male
NABUMETONE (500 MG, 750 MG) generic
NAPROXEN (125 MG/5ML ORAL SUSP, 500 MG TABLETDR, 250 MG TABLET, 375 MG TABLET, 500 MG TABLET,375 MG TABLET DR)
generic
PAGE 5 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
NAPROXEN SODIUM (550 MG, 275 MG) generic
oxaprozin 600 mg tablet generic
PIROXICAM (20 MG, 10 MG) generic
SALSALATE (750 MG, 500 MG) generic
SULINDAC (200 MG, 150 MG) generic
TOLMETIN SODIUM (600 MG TABLET, 400 MGCAPSULE, 200 MG TABLET)
generic
OPIOID ANALGESICS, LONG-ACTING
DISKETS 40 MG TABLET DISPRmethadone hcl
BRAND QL
FENTANYL (100, 12) genericPA
C 12 patches/28 days
FENTANYL (37.5MCG/HR, 87.5MCG/HR, 62.5MCG/HR) generic
QL
PA
C 12 patches/28 days
FENTANYL (50MCG/HR, 25MCG/HR, 75MCG/HR) generic
QL
PA
C 12 patches/28 days
HYDROMORPHONE HCL (16 MG ER, 12 MG ER) generic QL
hydromorphone hcl 32 mg tab er 24h generic QL
hydromorphone hcl 8 mg tab er 24h generic QL
levorphanol tartrate 2 mg tablet generic
methadone hcl 10 mg tablet generic QL
methadone hcl 10 mg/5 ml solution genericQL
C 40ml/day
methadone hcl 10 mg/ml oral conc genericQL
C 80ml/day
methadone hcl 10 mg/ml syringe generic QL
methadone hcl 10 mg/ml vial generic
methadone hcl 40 mg tablet sol generic QL
methadone hcl 5 mg tablet generic QL
PAGE 6 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
methadone hcl 5 mg/5 ml solution genericQL
C 80ml/day
METHADONE INTENSOL 10 MG/MLmethadone hcl
BRAND QL
METHADOSE 10 MG/ML ORAL CONCmethadone hcl
BRAND QL
METHADOSE 40 MG TABLET DISPRmethadone hcl
BRAND QL
MORPHINE SULFATE (100 MG ER, 200 MG ER) genericQL
PA
MORPHINE SULFATE (100 MG ER, 80 MG ER) generic QL
MORPHINE SULFATE (30 MG CPMP 24HR, 30 MG CAPER PEL)
generic QL
MORPHINE SULFATE (60 MG CPMP 24HR, 60 MG CAPER PEL, 50 MG CAP ER PEL)
generic QL
MORPHINE SULFATE (90 MG CPMP 24HR, 45 MGCPMP 24HR, 120 MG CPMP 24HR, 60 MG TABLET ER,75 MG CPMP 24HR)
genericQL
PA
morphine sulfate 10 mg cap er pel generic QL
morphine sulfate 15 mg tablet er genericQL
PA
morphine sulfate 20 mg cap er pel generic QL
morphine sulfate 30 mg tablet er genericQL
PA
oxycodone hcl 10 mg tab er 12h genericQL
PA
oxycodone hcl 20 mg tab er 12h genericQL
PA
oxycodone hcl 40 mg tab er 12h genericQL
PA
oxycodone hcl 80 mg tab er 12h genericQL
PA
OXYCONTIN (30 MG, 40 MG)oxycodone hcl
BRANDQL
PA
PAGE 7 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
OXYCONTIN (60 MG, 80 MG)oxycodone hcl
BRANDQL
PA
OXYCONTIN 10 MG TABLEToxycodone hcl
BRANDQL
PA
OXYCONTIN 15 MG TABLEToxycodone hcl
BRANDQL
PA
OXYCONTIN 20 MG TABLEToxycodone hcl
BRANDQL
PA
OXYMORPHONE HCL (20 MG ER, 15 MG ER) genericQL
PA
OXYMORPHONE HCL (40 MG ER, 30 MG ER) genericQL
PA
oxymorphone hcl 10 mg tab er 12h genericQL
PA
oxymorphone hcl 5 mg tab er 12h genericQL
PA
oxymorphone hcl 7.5 mg tab er 12h genericQL
PA
TRAMADOL HCL (100 MG CPBP 25-75, 100 MG TAB ER24H)
generic QL
TRAMADOL HCL (200 MG TBMP 24HR, 150 MG CPBP25-75, 100 MG TBMP 24HR, 300 MG TBMP 24HR)
genericQL
PA
TRAMADOL HCL (300 MG TAB ER 24H, 300 MG CPBP17-83, 200 MG TAB ER 24H, 200 MG CPBP 25-75)
generic QL
OPIOID ANALGESICS, SHORT-ACTING
acetaminophen with codeine 300mg-15mg tablet generic QL
acetaminophen with codeine 300mg-30mg tablet generic QL
acetaminophen with codeine 300mg-60mg tablet generic QL
ACETAMINOPHEN WITH CODEINE PHOSPHATE(300MG/12.5, 120-12MG/5)
generic C 150 ml/day
alfentanil hcl 500 mcg/ml ampul generic
ASCOMP WITH CODEINE CAPSULE BRAND QL
PAGE 8 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
codeine phosphate/butalbital/aspirin/caffeine
ASTRAMORPH-PF 1 MG/ML AMPULmorphine sulfate/pf
BRAND
BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEINEPHOSPHATE (50-325-30, 50-300-30)
generic QL
BUTORPHANOL TARTRATE (2 MG/ML, 1 MG/ML) generic
butorphanol tartrate 10 mg/ml spray genericQL
C 2 nasal sprayers or5ml/month
codeine sulfate 15 mg tablet generic QL
codeine sulfate 30 mg tablet generic QL
codeine sulfate 60 mg tablet generic QL
codeine/butalbital/asa/caffein 30-50-325 capsule generic QL
dhcodeine bt/acetaminophn/caff 16-320.5mg capsule generic
dihydrocodeine/aspirin/caffein 16-356-30 capsule generic QL
DURAMORPH (5 ML, 10 ML)morphine sulfate/pf
BRAND
ENDOCET (5-325, 2.5-325 MG)oxycodone hcl/acetaminophen
BRAND QL
ENDOCET 10-325 MG TABLEToxycodone hcl/acetaminophen
BRAND QL
ENDOCET 7.5-325 MG TABLEToxycodone hcl/acetaminophen
BRAND QL
ENDODAN 4.8355-325 MG TABLEToxycodone hcl/aspirin
BRAND QL
FENTANYL CITRATE (800 MCG, 1600 MCG, 1200 MCG) generic QL
fentanyl citrate 200 mcg lozenge hd generic QL
fentanyl citrate 400 mcg lozenge hd generic QL
fentanyl citrate 600 mcg lozenge hd generic QL
FENTANYL CITRATE IN 0.9 % SODIUM CHLORIDE/PF(10 MCG/ML SYRINGE, 20 MCG/ML PLAST. BAG)
generic
FENTANYL CITRATE/BUPIVACAINE HCL IN 0.9 %SODIUM CHLORIDE/PF (4MCG/ML-.1, 2MCG/ML-.1, 2-625MCG/1, 2-1250MCG)
generic GL Female
FENTANYL CITRATE/PF (50 MCG/ML AMPUL,100MCG/2ML SYRINGE, 50 MCG/ML VIAL)
generic
PAGE 9 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
HYDROCODONE BITARTRATE/ACETAMINOPHEN (2.5-167/5, 7.5-325/15, 5-217MG/10, 2.5-108/5)
generic C 32ml/day
HYDROCODONE BITARTRATE/ACETAMINOPHEN (5MG-325MG, 10MG-325MG, 5MG-300MG, 10MG-300MG,7.5-325MG, 7.5-300MG)
generic QL
hydrocodone/acetaminophen 2.5-325mg tablet generic QL
HYDROCODONE/IBUPROFEN (10MG-200MG, 5MG-200MG)
generic
hydrocodone/ibuprofen 2.5-200mg tablet generic QL
hydrocodone/ibuprofen 7.5-200 mg tablet generic QL
HYDROMORPHONE HCL (1 MG/ML SYRINGE, 2 MG/MLSYRINGE, 4 MG/ML SYRINGE, 2 MG/ML VIAL)
generic
hydromorphone hcl 1 mg/ml liquid generic QL
hydromorphone hcl 2 mg tablet generic QL
hydromorphone hcl 3 mg supp.rect generic QL
hydromorphone hcl 4 mg tablet generic QL
hydromorphone hcl 8 mg tablet generic QL
HYDROMORPHONE HCL/PF (1 MG/ML AMPUL, 10MG/ML AMPUL, 2 MG/ML AMPUL, 10 MG/ML VIAL, 4MG/ML AMPUL)
generic
ibuprofen/oxycodone hcl 400mg-5mg tablet generic QL
LORCET 5-325 MG TABLEThydrocodone bitartrate/acetaminophen
BRAND QL
LORCET HD 10-325 MG TABLEThydrocodone bitartrate/acetaminophen
BRAND QL
LORCET PLUS 7.5-325 MG TABLEThydrocodone bitartrate/acetaminophen
BRAND QL
LORTAB (10-325 MG, 5-325 MG, 7.5-325 MG)hydrocodone bitartrate/acetaminophen
BRAND QL
meperidine hcl 50 mg/5 ml solution genericQL
C 20ml/day
MORPHINE SULFATE (2 MG/ML CARTRIDGE,250MG/10ML VIAL PORT, 8 MG/ML VIAL, 4 MG/ML VIAL,25 MG/ML VIAL, 10 MG SUPP.RECT, 30 MGSUPP.RECT, 10 MG/ML VIAL, 10 MG/ML SYRINGE, 100MG/4ML VIAL PORT, 20 MG SUPP.RECT, 50 MG/MLVIAL, 15 MG/ML CARTRIDGE, 5 MG/ML VIAL, 15 MG/ML
generic
PAGE 10 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
VIAL, 8 MG/ML SYRINGE, 4 MG/ML SYRINGE, 4 MG/MLCARTRIDGE, 2 MG/ML SYRINGE, 10 MG/MLCARTRIDGE, 30 MG/30ML PCA SYRING, 5 MG/MLSYRINGE, 5 MG SUPP.RECT)
morphine sulfate 10 mg/5 ml solution genericQL
C 45ml/day
morphine sulfate 100 mg/5ml solution genericQL
C 9ml/day
morphine sulfate 15 mg tablet generic QL
morphine sulfate 20 mg/5 ml solution genericQL
C 45ml/day
morphine sulfate 30 mg tablet generic QL
MORPHINE SULFATE/PF (0.5 MG/ML, 1 MG/ML, 30MG/30ML PCA, 150MG/30ML PCA)
generic
morphine sulfate/pf 1 mg/2 ml syringe generic GL Male
NALBUPHINE HCL (10 MG/ML VIAL, 20 MG/ML VIAL, 10MG/ML AMPUL, 20 MG/ML AMPUL)
generic
OPIUM/BELLADONNA ALKALOIDS (60-16.2MG, 30-16.2MG)
generic
OXYCODONE HCL (5 MG CAPSULE, 5 MG TABLET) generic QL
oxycodone hcl 10 mg tablet generic QL
oxycodone hcl 15 mg tablet generic QL
oxycodone hcl 20 mg tablet generic QL
oxycodone hcl 20 mg/ml oral conc genericQL
C 8ml/day
oxycodone hcl 30 mg tablet generic QL
oxycodone hcl 5 mg/5 ml solution genericQL
C 80ml/day
OXYCODONE HCL/ACETAMINOPHEN (2.5-325MG, 5MG-325MG)
generic QL
oxycodone hcl/acetaminophen 10mg-325mg tablet generic QL
oxycodone hcl/acetaminophen 7.5-325mg tablet generic QL
oxycodone hcl/aspirin 4.8355-325 tablet generic QL
PAGE 11 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
oxymorphone hcl 10 mg tablet generic QL
oxymorphone hcl 5 mg tablet generic QL
pentazocine hcl/naloxone hcl 50mg-0.5mg tablet generic QL
REPREXAIN (10-200 MG, 2.5-200 MG, 5-200 MG)hydrocodone/ibuprofen
BRAND QL
ROXICET 5-325 TABLEToxycodone hcl/acetaminophen
BRAND QL
SUBLIMAZE 50 MCG/ML AMPULEfentanyl citrate/pf
BRAND
SUFENTA (50 MCG/ML AMPUL, 250 MCG/5 MLAMPULE, 100 MCG/2 ML AMPUL)sufentanil citrate
BRAND
sufentanil citrate 50 mcg/ml ampul generic
tramadol hcl 50 mg tablet generic QL
tramadol hcl/acetaminophen 37.5-325mg tablet generic QL
VERDROCET 2.5-325 MG TABLEThydrocodone bitartrate/acetaminophen
BRAND QL
VICODIN 5-300 MG TABLEThydrocodone bitartrate/acetaminophen
BRAND QL
VICODIN ES 7.5-300 MG TABLEThydrocodone bitartrate/acetaminophen
BRAND QL
VICODIN HP 10-300 MG TABLEThydrocodone bitartrate/acetaminophen
BRAND QL
ZAMICET 10-325 MG/15 ML SOLNhydrocodone bitartrate/acetaminophen
BRAND C 32ml/day
ANESTHETICS
LOCAL ANESTHETICS
BUFFERED LIDOCAINE 1% SYRINGElidocaine hcl buffered with 8.4 % sodium bicarbonate
BRAND
BUPIVACAINE HCL (2.5 MG/ML, 5 MG/ML) generic
bupivacaine hcl/dex-water/pf 0.75 % ampul generic
BUPIVACAINE HCL/EPINEPHRINE (0.25-.0005, 0.5-1:200K)
generic
BUPIVACAINE HCL/EPINEPHRINE/PF (0.5-1:200K, 0.25-.0005)
generic
PAGE 12 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
BUPIVACAINE HCL/PF (2.5 MG/ML VIAL, 2.5 MG/MLAMPUL, 7.5 MG/ML VIAL, 5 MG/ML VIAL, 5 MG/MLAMPUL, 7.5 MG/ML AMPUL)
generic
CARBOCAINE 1.5% VIALmepivacaine hcl/pf
BRAND
CHLOROPROCAINE HCL/PF (30 MG/ML, 20 MG/ML) generic
COMPOUND 347 INHALATIONenflurane
BRAND
etomidate 2 mg/ml vial generic
FORANE LIQUIDisoflurane
BRAND
isoflurane 99.9 % liquid generic
KETAMINE HCL (10 MG/ML, 50 MG/ML, 100 MG/ML) generic
LIDOCAINE HCL (20 MG/ML DISP SYRIN, 40 MG/MLSOLUTION, 100MG/10ML DISP SYRIN, 10 MG/ML DISPSYRIN, 30 MG/3 ML SYRINGE, 2 % SOLUTION)
generic
lidocaine hcl/d7.5w/pf 5 % ampul generic
LIDOCAINE HCL/DEXTROSE 5%-WATER/PF (8 MG/ML,4 MG/ML)
generic
LIDOCAINE HCL/EPINEPHRINE (2 %-1:100K, 1%-1:100K, 0.5-1:200K)
generic
LIDOCAINE HCL/EPINEPHRINE/PF (2%-1:200K VIAL,1.5-1:200K VIAL, 1.5-1:200K AMPUL)
generic
LIDOCAINE HCL/PF (50 MG/5 ML SYRINGE, 15 MG/MLAMPUL, 5 MG/ML VIAL, 10 MG/ML VIAL, 20 MG/MLAMPUL LUER, 100 MG/5ML SYRINGE, 10 MG/MLAMPUL, 40 MG/ML AMPUL, 20 MG/ML VIAL)
generic
NAROPIN (2 MG/ML INFUSION, 200 MG/100 ML INF,0.2% 400 MG/200 ML)ropivacaine hcl/pf
BRAND
POLOCAINE 1% VIALmepivacaine hcl
BRAND
POLOCAINE-MPF (1.5%, 2%, 1%)mepivacaine hcl/pf
BRAND
propofol 10 mg/ml vial generic
SENSORCAINE 0.5% VIALbupivacaine hcl
BRAND
SENSORCAINE-EPINEPHRINE (0.25%-EPI 1:200000,0.5%-EPI 1:200,000)bupivacaine hcl/epinephrine
BRAND
PAGE 13 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
SENSORCAINE-MPF 0.5% VIALbupivacaine hcl/pf
BRAND
sevoflurane liquid generic
SOJOURN INHALATION LIQUIDsevoflurane
BRAND
TERRELL LIQUIDisoflurane
BRAND
tetracaine hcl/pf 10 mg/ml ampul generic
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
ALCOHOL DETERRENTS/ANTI-CRAVING
acamprosate calcium 333 mg tablet dr generic
DEPADE 50 MG TABLETnaltrexone hcl
BRAND
DISULFIRAM (500 MG, 250 MG) generic
naltrexone hcl 50 mg tablet generic
OPIOID DEPENDENCE TREATMENTS
BUPRENORPHINE HCL (2 MG, 8 MG) genericQL
PA
buprenorphine hcl 0.3 mg/ml syringe generic PA
buprenorphine hcl 0.3 mg/ml vial generic
BUPRENORPHINE HCL/NALOXONE HCL (/NALOXONE8 MG-2 MG, /NALOXONE 2 MG-0.5MG)
genericQL
PA
SUBOXONE (12 MG-3 MG, 2 MG-0.5 MG, 4 MG-1 MG, 8MG-2 MG)buprenorphine hcl/naloxone hcl
BRANDQL
PA
OPIOID REVERSAL AGENTS
NALOXONE HCL (1 MG/ML, 0.4 MG/ML) generic QL
SMOKING CESSATION AGENTS
BUPROBAN 150 MG TABLETbupropion hcl
BRAND
bupropion hcl 150 mg tablet er generic
CHANTIX (0.5 MG, 1 MG)varenicline tartrate
BRAND QL
CHANTIX (1 MG CONT, STARTING)varenicline tartrate
BRAND
PAGE 14 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
ANTIBACTERIALS
AMINOGLYCOSIDES
AMIKACIN SULFATE (1000MG/4ML, 500 MG/2ML) generic
GENTAMICIN SULFATE (20 MG/2 ML, 40 MG/ML) generic
GENTAMICIN SULFATE IN SODIUM CHLORIDE, ISO-OSMOTIC (GENTAMIC90MG/100ML,GENTAMIC100MG/0.1L, GENTAMIC80 MG/50ML,GENTAMIC80MG/100ML, GENTAMIC60 MG/50ML,GENTAMIC70 MG/50ML)
generic
GENTAMICIN SULFATE/PF (20 MG/2 ML, 100MG/10MLPORT)
generic
neomycin sulfate 500 mg tablet generic
paromomycin sulfate 250 mg capsule generic
TOBRAMYCIN SULFATE (10 MG/ML, 40 MG/ML, 1.2 G) generic S Specialty Drug
TOBRAMYCIN SULFATE/SODIUM CHLORIDE (60MG/50ML, 80MG/100ML)
generic S Specialty Drug
ANTIBACTERIALS, OTHER
acetic acid 0.25 % irrig soln generic
BACIIM 50,000 UNITS VIALbacitracin
BRAND
bacitracin 50000 unit vial generic
BACTROBAN NASAL 2% OINTMENTmupirocin calcium
BRAND
chloramphenicol sod succ 1 g vial generic
CLINDAMYCIN HCL (150 MG, 75 MG, 300 MG) generic
clindamycin palmitate hcl 75 mg/5 ml soln recon generic
CLINDAMYCIN PHOSPHATE (300 MG/2ML VIAL PORT,2 % CREAM/APPL, 900MG/6ML VIAL PORT, 600MG/4ML VIAL PORT, 150 MG/ML VIAL)
generic
CLINDAMYCIN PHOSPHATE/DEXTROSE 5 % INWATER (300MG/50ML, 900MG/50ML, 600MG/50ML)
generic
colistin (colistimethate na) 150 mg vial generic
HYOPHEN TABLETmethenamine/methylene blue/benzoicacid/salicylate/hyoscy
BRAND
lincomycin hcl 300 mg/ml vial generic
LINEZOLID (600MG/300 IV SOLN, 600 MG TABLET, 100 generic
PAGE 15 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
MG/5ML SUSP RECON)
linezolid-0.9% sodium chloride 600mg/300 iv soln generic PA
methenamine hippurate 1 g tablet generic
METHENAMINE MANDELATE (500 MG, 1 G) generic
METRO IV 500 MG/100 MLmetronidazole in sodium chloride
BRAND
METRONIDAZOLE (250 MG TABLET, 0.75 % GELW/APPL, 500 MG TABLET, 375 MG CAPSULE)
generic
metronidazole/sodium chloride 500mg/0.1l piggyback generic
NEOMYCIN SULFATE/POLYMYXIN B SULFATE(AMPUL, VIAL)
generic
NITROFURANTOIN (25 MG/5 ML ORAL SUSP, 50 MGCAPSULE)
generic
NITROFURANTOIN MACROCRYSTAL (50 MG, 25 MG,100 MG)
generic
nitrofurantoin monohyd/m-cryst 100 mg capsule generic
PHOSPHASAL TABLETmethenamine/methylene blue/sodium phos/pnyl sal/hyoscsul
BRAND
polymyxin b sulfate 500k unit vial generic
SULFAMYLON 8.5% CREAMmafenide acetate
BRAND
TINIDAZOLE (250 MG, 500 MG) generic
trimethoprim 100 mg tablet generic
TYGACIL 50 MG VIALtigecycline
BRAND
UR N-C TABLETmethenamine/methylene blue/sodium phos/pnyl sal/hyoscsul
BRAND
URETRON D-S TABLETmethenamine/methylene blue/sodium phos/pnyl sal/hyoscsul
BRAND
URIMAR-T TABLETmethenamine/methylene blue/salicylate/sodiumphos/hyoscy
BRAND
URIN D.S. TABLETmethenamine/methylene blue/sodium phos/pnyl sal/hyoscsul
BRAND
URO-BLUE TABLETS BRAND
PAGE 16 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
methenamine/sodium phosphate,monobasic/methblue/hyosc sul
UROGESIC-BLUE TABLETmethenamine/sodium phosphate,monobasic/methblue/hyosc sul
BRAND
UROLET MB TABLETmethenamine/sodium phosphate,monobasic/methblue/hyosc sul
BRAND
UROPHEN MB TABLETmethenamine/methylene blue/benzoicacid/salicylate/hyoscy
BRAND
URYL TABLETmethenamine/sodium phosphate,monobasic/methblue/hyosc sul
BRAND
USTELL CAPSULEmethenamine/methylene blue/salicylate/sodiumphos/hyoscy
BRAND
UTIRA-C TABLETmethenamine/methylene blue/sodium phos/pnyl sal/hyoscsul
BRAND
VANCOMYCIN HCL (10 G VIAL, 250 MG CAPSULE, 500MG VIAL, 750 MG VIAL PORT, 125 MG CAPSULE, 1 GVIAL, 750 MG VIAL, 5 G VIAL, 1 G VIAL PORT, 500 MGVIAL PORT)
generic
VANCOMYCIN HCL/DEXTROSE 5 % IN WATER(500MG/0.1L FROZ.PIGGY, 1G/200ML FROZ.PIGGY,1.25 G/250 PLAST. BAG, 1.5G/250ML PLAST. BAG)
generic
VANCOMYCIN IN 0.9 % SODIUM CHLORIDE(1.5G/250ML, 750MG/.15L, 1.25 G/250)
generic
vancomycin in dextrose,iso-osm 750mg/.15l froz.piggy generic
VANDAZOLE VAGINAL 0.75% GELmetronidazole
BRAND
XIFAXAN (550 MG, 200 MG)rifaximin
BRAND
ZYVOX 100 MG/5 ML SUSPENSIONlinezolid
BRAND PA
BETA-LACTAM, CEPHALOSPORINS
CEFACLOR (500 MG TAB ER 12H, 125 MG/5ML SUSPRECON, 500 MG CAPSULE, 250 MG/5ML SUSP RECON,250 MG CAPSULE, 375 MG/5ML SUSP RECON)
generic
CEFADROXIL (500 MG CAPSULE, 500 MG/5ML SUSPRECON, 250 MG/5ML SUSP RECON, 1 G TABLET)
generic
PAGE 17 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
CEFAZOLIN SODIUM (300G BULKBAGINJ, 1 G VIAL, 20G VIAL, 10 G VIAL, 500 MG VIAL, 1 G VIAL PORT, 100 GBULKBAGINJ)
generic
CEFAZOLIN SODIUM IN 0.9 % SODIUM CHLORIDE (0.92 G/100 ML PLAST. BAG, 0.9 2 G/50 ML PIGGYBACK,0.9 2 G/10 ML SYRGE)
generic
cefazolin sodium/d5w 2 g/100 ml plast. bag generic
CEFAZOLIN SODIUM/DEXTROSE, ISO-OSMOTIC (2 MLPIGGYBACK, 1 ML FROZ.PIGGY, 1 ML PIGGYBACK)
generic
CEFDINIR (125 MG/5ML SUSP RECON, 300 MGCAPSULE, 250 MG/5ML SUSP RECON)
generic
CEFDITOREN PIVOXIL (200 MG, 400 MG) generic
CEFEPIME HCL (2, 1) generic
CEFEPIME HCL/DEXTROSE, ISO-OSMOTIC (1 G/50 ML,2 G/100 ML)
generic
CEFIXIME (200, 100) generic
CEFOTAXIME SODIUM (10 G, 2 G, 1 G, 500 MG) generic
CEFOTETAN DISODIUM (2, 10, 1) generic
CEFOXITIN SODIUM (2, 1, 10) generic
CEFOXITIN SODIUM/DEXTROSE, ISO-OSMOTIC (2 ML,1 ML)
generic
CEFPODOXIME PROXETIL (100 MG TABLET, 100MG/5ML SUSP RECON, 50 MG/5 ML SUSP RECON, 200MG TABLET)
generic
CEFPROZIL (250 MG TABLET, 250 MG/5ML SUSPRECON, 125 MG/5ML SUSP RECON, 500 MG TABLET)
generic
CEFTAZIDIME (1, 2, 6) generic
CEFTIBUTEN (400 MG CAPSULE, 180 MG/5ML SUSPRECON)
generic
CEFTRIAXONE SODIUM (1 G, 2 G PORT, 1 G PORT, 10G, 500 MG, 250 MG, 2 G)
generic
CEFTRIAXONE SODIUM/DEXTROSE, ISO-OSMOTIC (2ML FROZ.PIGGY, 2 ML PIGGYBACK, 1 ML PIGGYBACK,1 ML FROZ.PIGGY)
generic
CEFUROXIME AXETIL (250 MG, 500 MG) generic
CEFUROXIME SODIUM (7.5G, 750 MG, 7.5 G, 1.5 G) generic
CEFUROXIME SODIUM/DEXTROSE, ISO-OSMOTIC(750MG/50ML, 1.5G/50ML)
generic
CEPHALEXIN (250 MG TABLET, 250 MG CAPSULE, 750 generic
PAGE 18 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
MG CAPSULE, 500 MG TABLET, 250 MG/5ML SUSPRECON, 125 MG/5ML SUSP RECON, 500 MG CAPSULE)
BETA-LACTAM, OTHER
AZTREONAM (2, 1) generic
IMIPENEM/CILASTATIN SODIUM (250 MG, 500 MG) generic
MEROPENEM (500 MG, 1 G) generic
MEROPENEM IN 0.9 % SODIUM CHLORIDE (1 G/50 ML,500MG/50ML)
generic
BETA-LACTAM, PENICILLINS
AMOXICILLIN (250 MG CAPSULE, 500 MG TABLET, 400MG/5ML SUSP RECON, 500 MG CAPSULE, 125 MG TABCHEW, 250 MG TAB CHEW, 125 MG/5ML SUSP RECON,875 MG TABLET, 250 MG/5ML SUSP RECON, 200MG/5ML SUSP RECON)
generic
AMOXICILLIN/POTASSIUM CLAVULANATE (600-42.9/5SUSP RECON, 400-57MG TAB CHEW, 200-28.5MG TABCHEW, 875-125 MG TABLET, 400-57MG/5 SUSPRECON, 250-62.5/5 SUSP RECON, 250-125 MGTABLET, 200-28.5/5 SUSP RECON, 1000-62.5 TAB ER12H, 500-125 MG TABLET)
generic
AMPICILLIN SODIUM (500 MG, 10 G, 1 G, 2 G PORT, 2G, 1 G PORT, 250 MG, 125 MG)
generic
AMPICILLIN SODIUM/SULBACTAM SODIUM (15, 1.5PORT, 3, 3 PORT, 1.5)
generic
AMPICILLIN TRIHYDRATE (250 MG CAPSULE, 500 MGCAPSULE, 250 MG/5ML SUSP RECON, 125 MG/5MLSUSP RECON)
generic
DICLOXACILLIN SODIUM (500 MG, 250 MG) generic
NAFCILLIN IN DEXTROSE, ISO-OSMOTIC (1 G/50 ML, 2G/100 ML)
generic
NAFCILLIN SODIUM (2 PORT, 2, 1 PORT, 1, 10) generic
OXACILLIN SODIUM (10, 2 PORT, 1, 2, 1 PORT) generic
OXACILLIN SODIUM/DEXTROSE, ISO-OSMOTIC (2 ML,1 ML)
generic
PENICILLIN G POTASSIUM (5MM, 20MM) generic
PENICILLIN G PROCAINE (1.2MM/2 ML SYRINE,600000/ML SYRINE)
generic
penicillin g sodium 5mm unit vial generic
PENICILLIN V POTASSIUM (500 MG TABLET, 250 MGTABLET, 250 MG/5ML SOLN RECON, 125 MG/5ML generic
PAGE 19 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
SOLN RECON)
PFIZERPEN (20 UNIT, 5 UNITS)penicillin g potassium
BRAND
PIPERACILLIN SODIUM/TAZOBACTAM SODIUM (40.5,4.5, 3.375, 4.5 PORT, 3.375 PORT, 2.25 PORT, 2.25)
generic
MACROLIDES
AZITHROMYCIN (200 MG/5ML SUSP RECON, 500 MGVIAL PORT, 100 MG/5ML SUSP RECON, 500 MG VIAL, 1G PACKET, 250 MG TABLET)
generic
AZITHROMYCIN (500 MG, 600 MG) generic QL
CLARITHROMYCIN (250, 125) generic C 150ml/fill
CLARITHROMYCIN (500 MG TAB ER 24H, 500 MGTABLET, 250 MG TABLET)
generic QL
E.E.S. 200 MG/5 ML GRANULESerythromycin ethylsuccinate
BRAND
E.E.S. 400 FILMTABerythromycin ethylsuccinate
BRAND
ery e-succ/sulfisoxazole 200-600/5 susp recon generic
ERY-TAB (250 MG, 500 MG, 333 MG)erythromycin base
BRAND
ERYPED 200 MG/5 ML SUSPENSIONerythromycin ethylsuccinate
BRAND
ERYPED 400 MG/5 ML SUSPENSIONerythromycin ethylsuccinate
BRAND
ERYTHROCIN 250 MG FILMTABerythromycin stearate
BRAND
ERYTHROMYCIN BASE (500 MG TABLET, 250 MGTABLET, 250 MG CAPSULE DR)
generic
erythromycin ethylsuccinate 400 mg tablet generic
QUINOLONES
AVELOX IV 400 MG/250 MLmoxifloxacin hcl/sodium chloride, iso-osmotic
BRAND
CIPRO (5%, 10%)ciprofloxacin
BRAND C 10ml/day; 150ml/fill
CIPROFLOXACIN HCL (100 MG, 500 MG, 750 MG) generic QL
ciprofloxacin hcl 0.2 % droperette generic
ciprofloxacin hcl 250 mg tablet generic QL
PAGE 20 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
CIPROFLOXACIN LACTATE (400MG/40ML,200MG/20ML)
generic
CIPROFLOXACIN LACTATE/DEXTROSE 5 % IN WATER(400MG/0.2L, 200MG/0.1L)
generic
CIPROFLOXACIN/CIPROFLOXACIN HCL (500 MG, 1000MG)
generic QL
LEVOFLOXACIN (500 MG, 750 MG, 250 MG) generic C 5 tablets/30 days
levofloxacin 25 mg/ml vial generic
levofloxacin 250mg/10ml solution generic C 480ml/fill
LEVOFLOXACIN/DEXTROSE 5 % IN WATER(750MG/.15L, 250MG/50ML, 500MG/0.1L)
generic
moxifloxacin hcl 400 mg tablet generic QL
moxifloxacin/sod.ace,sul/water 400mg/.25l piggyback generic
OFLOXACIN (400 MG, 300 MG, 200 MG) generic
SULFONAMIDES
sulfadiazine 500 mg tablet generic
SULFAMETHOXAZOLE/TRIMETHOPRIM (800-160/20ORAL SUSP, 200-40MG/5 ORAL SUSP, 80-16MG/MLVIAL, 400MG-80MG TABLET, 800-160 MG TABLET)
generic
SULFATRIM PEDIATRIC SUSPENSIONsulfamethoxazole/trimethoprim
BRAND
TETRACYCLINES
AVIDOXY 100 MG TABLETdoxycycline monohydrate
BRAND
DEMECLOCYCLINE HCL (150 MG, 300 MG) generic
DOXYCYCLINE MONOHYDRATE (150 MG TABLET, 75MG CAPSULE, 50 MG CAPSULE, 100 MG TABLET, 75MG TABLET, 100 MG CAPSULE, 40 MG CAP IR DR, 150MG CAPSULE, 50 MG TABLET, 25 MG/5 ML SUSPRECON)
generic
MINOCYCLINE HCL (135 MG TAB ER 24H, 100 MGCAPSULE, 90 MG TAB ER 24H, 75 MG CAPSULE, 45MG TAB ER 24H, 100 MG TABLET, 50 MG TABLET, 75MG TABLET, 50 MG CAPSULE)
generic
MONDOXYNE NL (50 MG, 75 MG, 100 MG)doxycycline monohydrate
BRAND
OCUDOX CONVENIENCE KITdoxycycline hyclate/eyelid clns no.3/eyelid emollient no.1
BRAND
PAGE 21 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
TETRACYCLINE HCL (500 MG, 250 MG) generic
ANTICONVULSANTS
ANTICONVULSANTS, OTHER
LEVETIRACETAM (1000 MG TABLET, 500 MG/5MLSOLUTION, 500 MG TAB ER 24H, 100 MG/MLSOLUTION, 500 MG TABLET, 750 MG TABLET, 750 MGTAB ER 24H, 500 MG/5ML VIAL, 250 MG TABLET)
generic
POTIGA (50 MG, 300 MG, 200 MG, 400 MG)ezogabine
BRAND
CALCIUM CHANNEL MODIFYING AGENTS
CELONTIN 300 MG KAPSEALmethsuximide
BRAND
ETHOSUXIMIDE (250 MG/5ML SOLUTION, 250 MGCAPSULE)
generic
ZONISAMIDE (50 MG, 100 MG, 25 MG) generic
GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS
DIAZEPAM (12.5-15-20, 2.5 MG, 5-7.5-10MG) generic C 2 kits/30 days
DIVALPROEX SODIUM (125 MG TABLET DR, 250 MGTAB ER 24H, 125 MG CAP SPRINK, 500 MG TABLETDR, 500 MG TAB ER 24H, 250 MG TABLET DR)
generic
GABAPENTIN (250 MG/5ML SOLUTION, 800 MGTABLET, 100 MG CAPSULE, 300 MG/6ML SOLUTION,300 MG CAPSULE, 600 MG TABLET, 400 MG CAPSULE)
generic
GABITRIL (12 MG, 16 MG)tiagabine hcl
BRAND
ONFI (2.5 MG/ML SUSPENSION, 5 MG TABLET, 20 MGTABLET, 10 MG TABLET)clobazam
BRAND
PHENOBARBITAL (60 MG TABLET, 15 MG TABLET, 100MG TABLET, 64.8 MG TABLET, 30 MG TABLET, 97.2MGTABLET, 16.2 MG TABLET, 32.4 MG TABLET, 20 MG/5ML ELIXIR)
generic
PHENOBARBITAL SODIUM (130MG/ML, 65 MG/ML) generic
PRIMIDONE (250 MG, 50 MG) generic
SABRIL (500 MG TABLET, 500 MG POWDER PACKET)vigabatrin
BRAND S Specialty Drug
TIAGABINE HCL (4 MG, 2 MG) generic
VALPROIC ACID (AS SODIUM SALT) (VALPROATESODIUM) (500 MG/5ML VIAL, 250 MG/5ML SOLUTION, generic
PAGE 22 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
500MG/10ML SOLUTION)
valproic acid 250 mg capsule generic
GLUTAMATE REDUCING AGENTS
FELBAMATE (400 MG TABLET, 600 MG TABLET, 600MG/5ML ORAL SUSP)
generic
LAMOTRIGINE (50 MG TAB RAPDIS, 100 MG TAB ER24, 25-50-100 TB RD DSPK, 300 MG TAB ER 24, 5 MGTB CHW DSP, 100 MG TAB RAPDIS, 25MG (35) TAB DSPK, 200 MG TABLET, 200 MG TAB ER 24, 25(21)-50 TBRD DSPK, 150 MG TABLET, 50 MG TAB ER 24, 100 MGTABLET, 25 MG TABLET, 25 MG TAB ER 24, 250 MGTAB ER 24, 200 MG TAB RAPDIS, 25 MG TAB RAPDIS,50(42)-100 TB RD DSPK, 25 MG TB CHW DSP)
generic
TOPIRAGEN (200 MG, 50 MG, 25 MG, 100 MG)topiramate
BRAND
TOPIRAMATE (25 MG CAP SPRINK, 200 MG TABLET,50 MG TABLET, 25 MG TABLET, 100 MG TABLET, 15MG CAP SPRINK)
generic
SODIUM CHANNEL AGENTS
BANZEL (400 MG TABLET, 40 MG/ML SUSPENSION,200 MG TABLET)rufinamide
BRAND
CARBAMAZEPINE (400 MG TAB ER 12H, 200 MGTABLET, 300 MG CPMP 12HR, 200 MG TAB ER 12H, 200MG CPMP 12HR, 100 MG CPMP 12HR, 100 MG/5MLORAL SUSP, 100 MG TAB CHEW)
generic
DILANTIN 30 MG CAPSULEphenytoin sodium extended
BRAND
EPITOL 200 MG TABLETcarbamazepine
BRAND
FOSPHENYTOIN SODIUM (500 PE/10, 100MG PE/2) generic
OXCARBAZEPINE (150 MG TABLET, 300 MG TABLET,600 MG TABLET, 300 MG/5ML ORAL SUSP)
generic
PEGANONE 250 MG TABLETethotoin
BRAND
PHENYTOIN (50 MG TAB CHEW, 125 MG/5ML ORALSUSP, 100 MG/4ML ORAL SUSP)
generic
PHENYTOIN SODIUM (50 MG/ML SYRINGE, 50 MG/MLVIAL, 50 MG/ML AMPUL)
generic
PHENYTOIN SODIUM EXTENDED (300 MG, 100 MG,200 MG)
generic
PAGE 23 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
TEGRETOL XR 100 MG TABLETcarbamazepine
BRAND
VIMPAT (200 MG/20 ML VIAL, 10 MG/ML SOLUTION, 150MG TABLET, 100 MG TABLET, 200 MG TABLET, 50 MGTABLET)lacosamide
BRAND
ANTIDEMENTIA AGENTS
ANTIDEMENTIA AGENTS, OTHER
ergoloid mesylates 1 mg tablet generic
ISOXSUPRINE HCL (20 MG, 10 MG) generic
papaverine hcl 30 mg/ml vial generic
CHOLINESTERASE INHIBITORS
DONEPEZIL HCL (10 MG TABLET, 5 MG TAB RAPDIS,10 MG TAB RAPDIS, 23 MG TABLET, 5 MG TABLET)
generic
GALANTAMINE HBR (12 MG TABLET, 24 MG CAP24HPEL, 4 MG TABLET, 8 MG CAP24H PEL, 8 MG TABLET,16 MG CAP24H PEL, 4 MG/ML SOLUTION)
generic
RIVASTIGMINE (13.3MG/24H, 9.5MG/24HR,4.6MG/24HR)
generic
RIVASTIGMINE TARTRATE (1.5 MG, 6 MG, 4.5 MG, 3MG)
generic
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST
MEMANTINE HCL (10 MG, 5 MG) generic GL Male
MEMANTINE HCL (5 MG-10 MG TAB DS PK, 2 MG/MLSOLUTION)
generic
NAMENDA (10 MG TABLET, 5-10 MG TITRATION PK, 5MG TABLET, 2 MG/ML SOLUTION)memantine hcl
BRAND
ANTIDEPRESSANTS
ANTIDEPRESSANTS, OTHER
AMITRIPTYLINE HCL/CHLORDIAZEPOXIDE (25 MG-10MG, 12.5MG-5MG)
generic
BUDEPRION XL 300 MG TABLETbupropion hcl
BRAND QL
BUPROPION HCL (75 MG TABLET, 200 MG TABLET ER,150 MG TABLET ER, 100 MG TABLET ER, 300 MG TABER 24H, 100 MG TABLET)
generic
PAGE 24 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
bupropion hcl 150 mg tab er 24h generic QL
MIRTAZAPINE (15 MG TABLET, 45 MG TABLET, 7.5 MGTABLET, 45 MG TAB RAPDIS, 15 MG TAB RAPDIS, 30MG TABLET, 30 MG TAB RAPDIS)
generic
OLANZAPINE/FLUOXETINE HCL (6MG-50MG, 6MG-25MG, 12MG-25MG, 12MG-50MG, 3 MG-25 MG)
generic
PERPHENAZINE/AMITRIPTYLINE HCL (4 MG-25 MG,4MG-10MG, 2 MG-10 MG, 4 MG-50 MG, 2 MG-25 MG)
generic
MONOAMINE OXIDASE INHIBITORS
phenelzine sulfate 15 mg tablet generic
tranylcypromine sulfate 10 mg tablet generic
SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN AND NOREPINEPHRINEREUPTAKE INHIBITOR
CITALOPRAM HYDROBROMIDE (40 MG TABLET, 10MG TABLET, 20 MG TABLET, 10 MG/5 ML SOLUTION)
generic
ESCITALOPRAM OXALATE (20 MG TABLET, 10 MGTABLET, 5 MG/5 ML SOLUTION, 5 MG TABLET)
generic
FLUOXETINE HCL (20 MG TABLET, 40 MG CAPSULE,20 MG/5 ML SOLUTION, 90 MG CAPSULE DR, 10 MGTABLET, 20 MG CAPSULE, 10 MG CAPSULE)
generic
FLUVOXAMINE MALEATE (150 MG CAP ER 24H, 100MG CAP ER 24H, 25 MG TABLET, 100 MG TABLET, 50MG TABLET)
generic
MAPROTILINE HCL (25 MG, 75 MG, 50 MG) generic
PAROXETINE HCL (12.5 MG TAB ER 24H, 10 MGTABLET, 25 MG TAB ER 24H, 20 MG TABLET, 40 MGTABLET, 30 MG TABLET, 37.5 MG TAB ER 24H)
generic
SERTRALINE HCL (50 MG TABLET, 25 MG TABLET, 20MG/ML ORAL CONC, 100 MG TABLET)
generic
TRAZODONE HCL (100 MG, 50 MG, 300 MG, 150 MG) generic
VENLAFAXINE HCL (37.5 MG ER, 150 MG ER) generic
VENLAFAXINE HCL (50 MG, 25 MG, 37.5 MG, 100 MG) generic QL
venlafaxine hcl 225 mg tab er 24 generic QL
venlafaxine hcl 75 mg cap er 24h generic QL
venlafaxine hcl 75 mg tablet generic QL
TRICYCLICS
PAGE 25 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
AMITRIPTYLINE HCL (50 MG, 75 MG, 100 MG, 25 MG,10 MG, 150 MG)
generic
AMOXAPINE (25 MG, 100 MG, 50 MG, 150 MG) generic
CLOMIPRAMINE HCL (50 MG, 75 MG, 25 MG) generic
DESIPRAMINE HCL (10 MG, 75 MG, 100 MG, 25 MG, 50MG, 150 MG)
generic
DOXEPIN HCL (150 MG CAPSULE, 75 MG CAPSULE, 50MG CAPSULE, 25 MG CAPSULE, 100 MG CAPSULE, 10MG/ML ORAL CONC, 10 MG CAPSULE)
generic
IMIPRAMINE HCL (25 MG, 10 MG, 50 MG) generic
IMIPRAMINE PAMOATE (150 MG, 75 MG, 100 MG, 125MG)
generic
NORTRIPTYLINE HCL (50 MG CAPSULE, 10 MG/5 MLSOLUTION, 25 MG CAPSULE, 10 MG CAPSULE, 75 MGCAPSULE)
generic
PROTRIPTYLINE HCL (5 MG, 10 MG) generic
ANTIEMETICS
ANTIEMETICS, OTHER
COMPRO 25 MG SUPPOSITORYprochlorperazine
BRAND
dimenhydrinate 50 mg/ml vial generic
MECLIZINE HCL (25 MG, 12.5 MG) generic
METOCLOPRAMIDE HCL (10 MG TABLET, 5 MG TABRAPDIS, 5 MG TABLET, 10 MG/10ML SOLUTION, 10 MGTAB RAPDIS, 5 MG/ML VIAL, 5 MG/5 ML SOLUTION)
generic
PERPHENAZINE (16 MG, 2 MG, 4 MG, 8 MG) generic
prochlorperazine 25 mg supp.rect generic
PROCHLORPERAZINE EDISYLATE (10 MG/2 ML, 5MG/ML)
generic
PROCHLORPERAZINE MALEATE (5 MG, 10 MG) generic
TRIMETHOBENZAMIDE HCL (300 MG CAPSULE, 100MG/ML VIAL)
generic
EMETOGENIC THERAPY ADJUNCTS
DRONABINOL (10 MG, 2.5 MG, 5 MG) generic
EMEND (TRIPACK, 40 MG CAPSULE, 125 MGCAPSULE, 80 MG CAPSULE, 150 MG VIAL)aprepitant
BRAND S Specialty Drug
PAGE 26 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
GRANISETRON HCL (1 MG/ML(1), 1 MG/ML) genericPA
S Specialty Drug
granisetron hcl 1 mg tablet generic S Specialty Drug
GRANISETRON HCL/PF (100 MCG/ML, 1 MG/ML(1)) genericPA
S Specialty Drug
GRANISOL 2 MG/10 ML SOLUTIONgranisetron hcl
BRANDPA
C 50ml/30 days
ONDANSETRON (8 MG, 4 MG) generic QL
ONDANSETRON HCL (4 MG/5 ML SOLUTION, 24 MGTABLET)
generic
ONDANSETRON HCL (8 MG, 4 MG) generic QL
ondansetron hcl 2 mg/ml vial generic PA
ondansetron hcl/pf 4 mg/2 ml syringe genericPA
S Specialty Drug
ondansetron hcl/pf 4 mg/2 ml vial generic S Specialty Drug
ANTIFUNGALS
amphotericin b 50 mg vial generic
CANCIDAS (70 MG, 50 MG)caspofungin acetate
BRAND
CICLODAN 0.77% CREAMciclopirox olamine
BRAND
CICLOPIROX (1 SHAMPOO, 0.77 GEL (GRAM), 8SOLUTION)
generic
CICLOPIROX OLAMINE (0.77 CREAM (G), 0.77SUSPENSION)
generic
ciclopirox/ure/camph/menth/euc 8 % solution generic
econazole nitrate 1 % cream (g) generic
FIRST-BXN MOUTHWASHnystatin/lidocaine hcl/diphenhydramine hcl
BRAND
FLUCONAZOLE (10 MG/ML SUSP RECON, 50 MGTABLET, 40 MG/ML SUSP RECON, 100 MG TABLET)
generic
FLUCONAZOLE (150 MG, 200 MG) generic QL
FLUCONAZOLE IN DEXTROSE, ISO-OSMOTIC(400MG/0.2L, 200MG/0.1L)
generic
PAGE 27 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
FLUCONAZOLE IN SODIUM CHLORIDE, ISO-OSMOTIC(200MG/0.1L PGGYBK BTL, 400MG/0.2L PGGYBK BTL,100MG/50ML PGGYBK BTL, 200MG/0.1L PIGGYBACK,400MG/0.2L PIGGYBACK)
generic
FLUCYTOSINE (500 MG, 250 MG) generic
GRISEOFULVIN ULTRAMICROSIZE (125 MG, 250 MG) generic
GRISEOFULVIN, MICROSIZE (500 MG TABLET, 125MG/5ML ORAL SUSP)
generic
GYNAZOLE 1 2% CREAMbutoconazole nitrate
BRAND
itraconazole 100 mg capsule generic
KETOCONAZOLE (2 CREAM (G), 2 FOAM, 2 SHAMPOO) generic
ketoconazole 200 mg tablet generic QL
KETODAN (KIT, )ketoconazole/skin cleanser combination no.28
BRAND
LAMISIL (187.5 MG PACK, 125 MG PACKET)terbinafine hcl
BRAND
miconazole nitrate 200 mg supp.vag generic
MYCAMINE (50 MG, 100 MG)micafungin sodium
BRAND
NATACYN EYE DROPSnatamycin
BRAND
NOXAFIL (40 MG/ML SUSPENSION, 300 MG/16.7 MLVIAL, DR 100 MG TABLET)posaconazole
BRAND
NYAMYC 100,000 UNITS/GM POWDERnystatin
BRAND
NYSTATIN (100000/ML ORAL SUSP, 500MM UNITPOWDER(EA), 150MM UNIT POWDER(EA), 100000/GPOWDER, 100000/G CREAM (G), 100000/G OINT. (G),50MM UNIT POWDER(EA), 500K UNIT TABLET)
generic
NYSTATIN/TRIAMCINOLONE ACETONIDE (CREAM,OINT.)
generic
NYSTOP 100,000 UNITS/GM POWDERnystatin
BRAND
PEDI-DRI TOPICAL POWDERnystatin
BRAND
SPORANOX 10 MG/ML SOLUTIONitraconazole
BRAND
terbinafine hcl 250 mg tablet generic C max 84 days
PAGE 28 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
therapy/365 days
TERCONAZOLE (0.4 % CREAM/APPL, 80 MGSUPP.VAG, 0.8 % CREAM/APPL)
generic
triacetin 100 % liquid generic
VORICONAZOLE (200 MG VIAL, 200 MG/5ML SUSPRECON, 50 MG TABLET)
generic
voriconazole 200 mg tablet generic QL
ANTIGOUT AGENTS
ALLOPURINOL (300 MG, 100 MG) generic
allopurinol sodium 500 mg vial generic
ALOPRIM 500 MG VIALallopurinol sodium
BRAND
COLCHICINE (0.6 MG CAPSULE, 0.6 MG TABLET) generic
colchicine/probenecid 0.5-500mg tablet generic
COLCRYS 0.6 MG TABLETcolchicine
BRAND PA
probenecid 500 mg tablet generic
ULORIC (40 MG, 80 MG)febuxostat
BRAND
ANTIMIGRAINE AGENTS
ERGOT ALKALOIDS
DIHYDROERGOTAMINE MESYLATE (1 MG/ML AMPUL,1 MG/ML VIAL, 0.5MG/SPRY SPRAY/PUMP)
generic
ergotamine tartrate/caffeine 1 mg-100mg tablet generic
MIGERGOT SUPPOSITORYergotamine tartrate/caffeine
BRAND
SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS
ALMOTRIPTAN MALATE (12.5 MG, 6.25 MG) generic
NARATRIPTAN HCL (2.5 MG, 1 MG) generic QL
RIZATRIPTAN BENZOATE (10 MG TABLET, 5 MGTABLET, 5 MG TAB RAPDIS, 10 MG TAB RAPDIS)
generic
SUMATRIPTAN (20 MG, 5 MG) generic C 6 nasal sprayers/month
SUMATRIPTAN SUCCINATE (50 MG, 100 MG, 25 MG) generic
SUMATRIPTAN SUCCINATE (6 PEN INJCTR, 6 generic C 4 injections (2
PAGE 29 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
SYRINGE, 6 CARTRIDGE, 4 PEN INJCTR, 4CARTRIDGE, 6 VIAL)
kits)/month
ZOLMITRIPTAN (5 MG TAB RAPDIS, 2.5 MG TABRAPDIS, 5 MG TABLET, 2.5 MG TABLET)
generic
ZOMIG (2.5 MG, 5 MG)zolmitriptan
BRAND C 6 nasal sprayers/month
ANTIMYASTHENIC AGENTS
PARASYMPATHOMIMETICS
ENLON 10 MG/ML VIALedrophonium chloride
BRAND
guanidine hcl 125 mg tablet generic
MESTINON (180 MG TIMESPAN, 60 MG/5 ML SYRUP)pyridostigmine bromide
BRAND
NEOSTIGMINE METHYLSULFATE (4 MG/4 MLSYRINGE, 1 MG/ML VIAL, 2 MG/2 ML SYRINGE, 1:2000VIAL, 1:1000 VIAL, 3 MG/3 ML SYRINGE, 0.5 MG/MLVIAL)
generic
PROSTIGMIN 15 MG TABLETneostigmine bromide
BRAND
PYRIDOSTIGMINE BROMIDE (180 MG ER, 60 MG) generic
REGONOL 10 MG/2 ML AMPULpyridostigmine bromide
BRAND
ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS, OTHER
DAPSONE (100 MG, 25 MG) generic
MYCOBUTIN 150 MG CAPSULErifabutin
BRAND
rifabutin 150 mg capsule generic
ANTITUBERCULARS
ETHAMBUTOL HCL (100 MG, 400 MG) generic
ISONIAZID (50 MG/5 ML SOLUTION, 100 MG/ML VIAL,300 MG TABLET, 100 MG TABLET)
generic
PRIFTIN 150 MG TABLETrifapentine
BRAND
pyrazinamide 500 mg tablet generic
RIFAMPIN (600 MG VIAL, 150 MG CAPSULE, 300 MGCAPSULE)
generic
PAGE 30 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
SIRTURO 100 MG TABLETbedaquiline fumarate
BRAND
ANTINEOPLASTICS
ALKYLATING AGENTS
ALKERAN 2 MG TABLETmelphalan
BRAND
BICNU 100 MG VIALcarmustine
BRAND
BUSULFEX 60 MG/10 ML VIALbusulfan
BRAND
CYCLOPHOSPHAMIDE (25 MG TABLET, 2 G VIAL, 50MG TABLET, 500 MG VIAL, 1 G VIAL)
generic
DACARBAZINE (200 MG, 100 MG) generic
DAUNOXOME (2 MG/ML, 50 MG (2 MG/ML))daunorubicin citrate liposomal
BRAND
GLEOSTINE (40 MG, 100 MG, 10 MG, 5 MG)lomustine
BRAND
HEXALEN 50 MG CAPSULEaltretamine
BRAND S Specialty Drug
IFOSFAMIDE (1 G/20 ML, 3G/60ML, 3 G, 1 G) generic
IFOSFAMIDE/MESNA (1G-1G, 3G-1G) generic
LEUKERAN 2 MG TABLETchlorambucil
BRAND S Specialty Drug
LOMUSTINE (100 MG, 10 MG, 40 MG) generic S Specialty Drug
MATULANE 50 MG CAPSULEprocarbazine hcl
BRAND S Specialty Drug
melphalan hcl 50 mg vial generic
MUSTARGEN 10 MG VIALmechlorethamine hcl
BRAND MED Medical Drug
MYLERAN 2 MG TABLETbusulfan
BRAND
TEMODAR 100 MG VIALtemozolomide
BRAND S Specialty Drug
TEMOZOLOMIDE (5 MG, 20 MG, 140 MG, 100 MG, 180MG, 250 MG)
generic S Specialty Drug
TREANDA (100 MG, 25 MG)bendamustine hcl
BRAND
VALCHLOR 0.016% GEL BRAND
PAGE 31 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
mechlorethamine hcl
ZANOSAR 1 GM POWDER VIALstreptozocin
BRAND
ANTIANDROGENS
bicalutamide 50 mg tablet generic S Specialty Drug
flutamide 125 mg capsule generic
NILANDRON 150 MG TABLETnilutamide
BRAND S Specialty Drug
XTANDI 40 MG CAPSULEenzalutamide
BRAND S Specialty Drug
ZYTIGA 250 MG TABLETabiraterone acetate
BRAND S Specialty Drug
ANTIANGIOGENIC AGENTS
POMALYST (3 MG, 2 MG, 4 MG, 1 MG)pomalidomide
BRAND S Specialty Drug
REVLIMID (2.5 MG, 15 MG, 5 MG, 10 MG, 25 MG, 20 MG)lenalidomide
BRAND S Specialty Drug
THALOMID (50 MG, 150 MG, 100 MG, 200 MG)thalidomide
BRAND S Specialty Drug
ANTIESTROGENS/MODIFIERS
EMCYT 140 MG CAPSULEestramustine phosphate sodium
BRAND
FARESTON 60 MG TABLETtoremifene citrate
BRAND S Specialty Drug
TAMOXIFEN CITRATE (10 MG, 20 MG) generic
ANTIMETABOLITES
ADRUCIL (2,500 MG/50 ML, 500 MG/10 ML, 5 GRAM/100ML)fluorouracil
BRAND S Specialty Drug
ALIMTA (500 MG, 100 MG)pemetrexed disodium
BRAND
CAPECITABINE (500 MG, 150 MG) generic S Specialty Drug
cladribine 10 mg/10ml vial generic
cytarabine 20 mg/ml vial generic S Specialty Drug
CYTARABINE/PF (2 G/20 ML, 100 MG, 1 G, 500 MG, 20MG/ML, 100 MG/5ML)
generic S Specialty Drug
DROXIA (400 MG, 200 MG, 300 MG) BRAND
PAGE 32 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
hydroxyurea
ELITEK (1.5 MG, 7.5 MG)rasburicase
BRAND
floxuridine 500 mg vial generic MED Medical Drug
FLUOROURACIL (2.5 G/50ML, 1 G/20 ML, 5 G/100 ML,500MG/10ML)
generic S Specialty Drug
FLUOROURACIL (5 SOLUTION, 2 SOLUTION, 5 CREAM(G))
generic
FOLOTYN (20 MG/ML, 40 MG/2 ML)pralatrexate
BRAND
GEMCITABINE HCL (200 MG, 2 G, 1 G, 2 G/52.6ML,200MG/5.26, 1 G/26.3ML)
generic
hydroxyurea 500 mg capsule generic
mercaptopurine 50 mg tablet generic
pentostatin 10 mg vial generic
PURINETHOL 50 MG TABLETmercaptopurine
BRAND PA
TABLOID 40 MG TABLETthioguanine
BRAND S Specialty Drug
ANTINEOPLASTICS, OTHER
ABRAXANE 100 MG VIALpaclitaxel protein-bound
BRAND
ADRIAMYCIN (50 MG, 10 MG, 2 MG/ML, 200 MG/100 ML,20 MG)doxorubicin hcl
BRAND
amifostine crystalline 500 mg vial generic
ARRANON 250 MG VIALnelarabine
BRAND
CARBOPLATIN (10 MG/ML, 150 MG) generic
CERUBIDINE 20 MG VIALdaunorubicin hcl
BRAND
cisplatin 1 mg/ml vial generic
dactinomycin 0.5 mg vial generic
DAUNORUBICIN HCL (20 MG, 5 MG/ML) generic
decitabine 50 mg vial generic
DEXRAZOXANE HCL (250 MG, 500 MG) generic
DOCETAXEL (20 MG/2 ML, 160 MG/8ML, FNL 20MG/2, generic
PAGE 33 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
20MG/ML(1), 200MG/20ML, 160MG/16ML, 140 MG/7ML,80 MG/8 ML, 80 MG/4 ML, FNL 80MG/8)
DOXIL 2 MG/ML VIALdoxorubicin hcl pegylated liposomal
BRAND
DOXORUBICIN HCL (50 MG, 10 MG, 50 MG/25ML, 20MG/10ML, 2 MG/ML, 10 MG/5 ML)
generic
doxorubicin hcl peg-liposomal 2 mg/ml vial generic
ELOXATIN (200 MG/40 ML, 100 MG/20 ML, 50 MG/10ML)oxaliplatin
BRAND
EPIRUBICIN HCL (50 MG, 50 MG/25ML, 200 MG,200MG/0.1L)
generic
FLUDARABINE PHOSPHATE (50 MG, 50 MG/2 ML) generic
FUSILEV I.V. 50 MG VIALlevoleucovorin calcium
BRAND
idarubicin hcl 1 mg/ml vial generic
IRINOTECAN HCL (40 MG/2 ML, 100 MG/5ML,500MG/25ML)
generic
ISTODAX 10 MG VIALromidepsin
BRAND
IXEMPRA (15 MG, 45 MG)ixabepilone
BRAND
LEUCOVORIN CALCIUM (100 MG VIAL, 500MG/50MLVIAL, 500 MG VIAL, 50 MG VIAL, 200 MG VIAL, 350 MGVIAL, 10 MG TABLET, 5 MG TABLET, 25 MG TABLET, 15MG TABLET)
generic S Specialty Drug
leucovorin calcium 10 mg/ml vial generic
levoleucovorin calcium 10 mg/ml vial generic
LIPODOX 2 MG/ML VIALdoxorubicin hcl pegylated liposomal
BRAND
LIPODOX 50 2 MG/ML VIALdoxorubicin hcl pegylated liposomal
BRAND
LYSODREN 500 MG TABLETmitotane
BRAND S Specialty Drug
MARQIBO KITvincristine sulfate liposomal
BRAND
mesna 100 mg/ml vial generic
MESNEX 400 MG TABLETmesna
BRAND
MITOMYCIN (5 MG, 40 MG, 20 MG) generic
PAGE 34 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
mitoxantrone hcl 2 mg/ml vial generic
ONXOL 30 MG/5 ML VIALpaclitaxel
BRAND
OXALIPLATIN (50 MG, 100 MG, 50 MG/10ML,100MG/20ML)
generic
paclitaxel 6 mg/ml vial generic
PHOTOFRIN 75 MG VIALporfimer sodium
BRAND
SYLATRON (200 MCG, 600 MCG, 300 MCG)peginterferon alfa-2b
BRAND S Specialty Drug
SYLATRON 4-PACK (300 MCG, 200 MCG)peginterferon alfa-2b
BRAND S Specialty Drug
SYLATRON 888 MCG 4-PACKpeginterferon alfa-2b
BRAND
teniposide 50 mg/5 ml ampul generic
THERACYS 81 MG VIALbcg live
BRAND MED Medical Drug
thiotepa 15 mg vial generic
TRISENOX 10 MG/10 ML AMPULEarsenic trioxide
BRAND
VINBLASTINE SULFATE (1 MG/ML, 10 MG) generic
VINCASAR PFS (2 MG/2 ML, 1 MG/ML)vincristine sulfate
BRAND
VINCRISTINE SULFATE (2 MG/2 ML, 1 MG/ML) generic
VINORELBINE TARTRATE (50 MG/5 ML, 10 MG/ML) generic
VUMON 50 MG/5 ML AMPULEteniposide
BRAND
ZOLINZA 100 MG CAPSULEvorinostat
BRAND S Specialty Drug
AROMATASE INHIBITORS, 3RD GENERATION
anastrozole 1 mg tablet generic S Specialty Drug
exemestane 25 mg tablet generic S Specialty Drug
letrozole 2.5 mg tablet generic S Specialty Drug
ENZYME INHIBITORS
ETOPOSIDE (20 MG/ML VIAL, 50 MG CAPSULE) generic S Specialty Drug
TOPOSAR (100 MG/5 ML, 500 MG/25 ML, 1,000 MG/50 BRAND S Specialty Drug
PAGE 35 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
ML)etoposide
MOLECULAR TARGET INHIBITORS
AFINITOR (10 MG, 7.5 MG, 2.5 MG, 5 MG)everolimus
BRAND S Specialty Drug
AFINITOR DISPERZ (2 MG, 5 MG, 3 MG)everolimus
BRAND S Specialty Drug
BOSULIF (500 MG, 100 MG)bosutinib
BRAND S Specialty Drug
CAPRELSA (300 MG, 100 MG)vandetanib
BRAND S Specialty Drug
ERIVEDGE 150 MG CAPSULEvismodegib
BRAND S Specialty Drug
GILOTRIF (20 MG, 40 MG, 30 MG)afatinib dimaleate
BRAND S Specialty Drug
GLEEVEC (100 MG, 400 MG)imatinib mesylate
BRAND S Specialty Drug
IBRANCE (125 MG, 100 MG, 75 MG)palbociclib
BRANDPA
S Specialty Drug
ICLUSIG 15 MG TABLETponatinib hcl
BRAND S Specialty Drug
ICLUSIG 45 MG TABLETponatinib hcl
BRAND
IMATINIB MESYLATE (400 MG, 100 MG) generic S Specialty Drug
IMBRUVICA 140 MG CAPSULEibrutinib
BRAND
QL
PA
S Specialty Drug
INLYTA (5 MG, 1 MG)axitinib
BRAND S Specialty Drug
JAKAFI (10 MG, 15 MG, 5 MG, 25 MG, 20 MG)ruxolitinib phosphate
BRAND S Specialty Drug
MEKINIST (2 MG, 0.5 MG)trametinib dimethyl sulfoxide
BRAND S Specialty Drug
NEXAVAR 200 MG TABLETsorafenib tosylate
BRAND S Specialty Drug
SPRYCEL (80 MG, 20 MG, 140 MG, 70 MG, 100 MG, 50MG)dasatinib
BRAND S Specialty Drug
PAGE 36 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
STIVARGA 40 MG TABLETregorafenib
BRAND S Specialty Drug
SUTENT (50 MG, 12.5 MG, 25 MG)sunitinib malate
BRAND S Specialty Drug
TAFINLAR (50 MG, 75 MG)dabrafenib mesylate
BRAND S Specialty Drug
TARCEVA (150 MG, 100 MG, 25 MG)erlotinib hcl
BRAND S Specialty Drug
TASIGNA (150 MG, 200 MG)nilotinib hcl
BRAND S Specialty Drug
TORISEL 25 MG KITtemsirolimus
BRAND
TYKERB 250 MG TABLETlapatinib ditosylate
BRANDPA
S Specialty Drug
VOTRIENT 200 MG TABLETpazopanib hcl
BRAND S Specialty Drug
XALKORI (200 MG, 250 MG)crizotinib
BRAND S Specialty Drug
ZELBORAF 240 MG TABLETvemurafenib
BRAND S Specialty Drug
ZYDELIG (100 MG, 150 MG)idelalisib
BRANDPA
S Specialty Drug
ZYKADIA 150 MG CAPSULEceritinib
BRAND
QL
PA
S Specialty Drug
MONOCLONAL ANTIBODIES
ARZERRA (1,000 MG/50 ML, 100 MG/5 ML)ofatumumab
BRAND
AVASTIN (100 MG/4 ML, 400 MG/16 ML)bevacizumab
BRAND
BEXXAR (14 MG/ML DOSIMETRIC, 14 MG/MLTHERAPEUTIC)tositumomab (with maltose)
BRAND
ERBITUX (100 MG/50 ML, 200 MG/100 ML)cetuximab
BRAND
HERCEPTIN 440 MG VIALtrastuzumab
BRAND PA
KADCYLA (160 MG, 100 MG) BRAND PA
PAGE 37 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
ado-trastuzumab emtansine
PERJETA 420 MG/14 ML VIALpertuzumab
BRAND
RITUXAN 10 MG/ML VIALrituximab
BRAND PA
VECTIBIX (100 MG/5 ML, 400 MG/20 ML)panitumumab
BRAND
ZEVALIN Y-90 VIALkit for prep yttrium-90/ibritumomab tiuxetan/albumin human
BRAND
RETINOIDS
bexarotene 75 mg capsule generic
TARGRETIN (1% GEL, 75 MG CAPSULE)bexarotene
BRAND S Specialty Drug
TARGRETIN 75 MG SOFTGELbexarotene
BRAND
tretinoin 10 mg capsule generic
ANTIPARASITICS
ANTIHELMINTHICS
ALBENZA 200 MG TABLETalbendazole
BRAND
STROMECTOL 3 MG TABLETivermectin
BRAND
ANTIPROTOZOALS
ALINIA (500 MG TABLET, 100 MG/5 ML SUSPENSION)nitazoxanide
BRAND
atovaquone 750 mg/5ml oral susp generic
ATOVAQUONE/PROGUANIL HCL (250-100 MG, 62.5-25MG)
generic
CHLOROQUINE PHOSPHATE (500 MG, 250 MG) generic
COARTEM TABLETSartemether/lumefantrine
BRAND
DARAPRIM 25 MG TABLETpyrimethamine
BRAND
hydroxychloroquine sulfate 200 mg tablet generic
mefloquine hcl 250 mg tablet generic
MEPRON 750 MG/5 ML SUSPENSIONatovaquone
BRAND
PAGE 38 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
NEBUPENT 300 MG INHAL POWDERpentamidine isethionate
BRAND
quinine sulfate 324 mg capsule generic
PEDICULICIDES/SCABICIDES
EURAX (CREAM, LOTION)crotamiton
BRAND
malathion 0.5 % lotion generic
ST
C
60ml/fill; must trypermethrin andpiperonylbutoxide/pyrethrins
ANTIPARKINSON AGENTS
ANTICHOLINERGICS
BENZTROPINE MESYLATE (2 MG/2 ML VIAL, 2 MG/2 MLAMPUL, 1 MG TABLET, 2 MG TABLET, 0.5 MG TABLET)
generic
TRIHEXYPHENIDYL HCL (2 MG/5 ML ELIXIR, 2 MGTABLET, 5 MG TABLET)
generic
ANTIPARKINSON AGENTS, OTHER
AMANTADINE HCL (100 MG TABLET, 100 MGCAPSULE, 50 MG/5 ML SOLUTION)
generic
CARBIDOPA/LEVODOPA/ENTACAPONE (50-200-200,37.5-150MG, 18.75-75MG, 25-100-200, 31.25-125, 12.5-50 MG)
generic
entacapone 200 mg tablet generic
TASMAR 100 MG TABLETtolcapone
BRAND
tolcapone 100 mg tablet generic
DOPAMINE AGONISTS
APOKYN 30 MG/3 ML CARTRIDGEapomorphine hcl
BRAND S Specialty Drug
BROMOCRIPTINE MESYLATE (2.5 MG TABLET, 5 MGCAPSULE)
generic
PRAMIPEXOLE DI-HCL (0.375 MG TAB ER 24H, 1.5 MGTABLET, 0.125 MG TABLET, 2.25 MG TAB ER 24H, 0.5MG TABLET, 1.5 MG TAB ER 24H, 4.5 MG TAB ER 24H,0.25 MG TABLET, 0.75 MG TAB ER 24H, 3 MG TAB ER24H, 0.75 MG TABLET, 1 MG TABLET)
generic
ROPINIROLE HCL (3 MG TABLET, 2 MG TAB ER 24H, 8MG TAB ER 24H, 1 MG TABLET, 5 MG TABLET, 12 MG generic
PAGE 39 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
TAB ER 24H, 6 MG TAB ER 24H, 0.5 MG TABLET, 4 MGTABLET, 4 MG TAB ER 24H, 0.25 MG TABLET, 2 MGTABLET)
DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS
carbidopa 25 mg tablet generic
CARBIDOPA/LEVODOPA (25MG-250MG TAB RAPDIS,25MG-250MG TABLET, 25MG-100MG TAB RAPDIS,25MG-100MG TABLET ER, 10MG-100MG TAB RAPDIS,50MG-200MG TABLET ER, 10MG-100MG TABLET,25MG-100MG TABLET)
generic
MONOAMINE OXIDASE B (MAO-B) INHIBITORS
SELEGILINE HCL (5 MG TABLET, 5 MG CAPSULE) generic
ANTIPSYCHOTICS
1ST GENERATION/TYPICAL
CHLORPROMAZINE HCL (100 MG TABLET, 200 MGTABLET, 25 MG TABLET, 10 MG TABLET, 25 MG/MLAMPUL, 50 MG TABLET)
generic
DROPERIDOL (2.5 MG/ML AMPUL, 2.5 MG/ML VIAL) generic
fluphenazine decanoate 25 mg/ml vial generic
FLUPHENAZINE HCL (2.5 MG/5ML ELIXIR, 10 MGTABLET, 5 MG TABLET, 2.5 MG TABLET, 5 MG/MLORAL CONC, 2.5 MG/ML VIAL, 1 MG TABLET)
generic
HALOPERIDOL (20 MG, 0.5 MG, 2 MG, 10 MG, 1 MG, 5MG)
generic
HALOPERIDOL DECANOATE (50 MG/ML VIAL, 100MG/ML AMPUL, 50 MG/ML AMPUL, 100 MG/ML VIAL)
generic
HALOPERIDOL LACTATE (2 MG/ML ORAL CONC, 5MG/ML VIAL, 5 MG/ML AMPUL)
generic
LOXAPINE SUCCINATE (10 MG, 5 MG, 50 MG, 25 MG) generic
MOLINDONE HCL (10 MG, 5 MG, 25 MG) generic GL Male
PIMOZIDE (2 MG, 1 MG) generic
THIORIDAZINE HCL (50 MG, 10 MG, 25 MG, 100 MG) generic
THIOTHIXENE (1 MG, 10 MG, 2 MG, 5 MG) generic
TRIFLUOPERAZINE HCL (10 MG, 1 MG, 2 MG, 5 MG) generic
2ND GENERATION/ATYPICAL
ABILIFY (10 MG, 30 MG, 20 MG, 15 MG, 5 MG)aripiprazole
BRAND QL
PAGE 40 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
ABILIFY 1 MG/ML SOLUTIONaripiprazole
BRAND C 30ml/DAY
ABILIFY 2 MG TABLETaripiprazole
BRAND QL
ABILIFY 9.7 MG/1.3 ML VIALaripiprazole
BRAND C 30ml/day
ABILIFY DISCMELT (10 MG, 15 MG)aripiprazole
BRAND QL
ABILIFY MAINTENA ER 300 MG SYRaripiprazole
BRANDQL
PA
ABILIFY MAINTENA ER 300 MG VLaripiprazole
BRANDPA
C 30ml/day
ABILIFY MAINTENA ER 400 MG SYRaripiprazole
BRANDQL
PA
ABILIFY MAINTENA ER 400 MG VLaripiprazole
BRANDPA
C 30ml/DAY
ARIPIPRAZOLE (15 MG, 10 MG) generic QL
ARIPIPRAZOLE (15 MG, 10 MG, 30 MG, 5 MG, 20 MG, 2MG)
generic QL
aripiprazole 1 mg/ml solution generic QL
GEODON 20 MG/ML VIALziprasidone mesylate
BRAND
INVEGA SUSTENNA (156 MG SY, 117 MG SY, 39 MGSYR, 234 MG SY, 78 MG SYR)paliperidone palmitate
BRANDPA
C must try 1 oralantipsychotic
INVEGA TRINZA (819 MG/2.625 ML, 546 MG/1.75 ML)paliperidone palmitate
BRAND
QL
PA
ST
INVEGA TRINZA 273 MG/0.875 MLpaliperidone palmitate
BRAND
QL
PA
ST
INVEGA TRINZA 410 MG/1.315 MLpaliperidone palmitate
BRAND
QL
PA
ST
OLANZAPINE (10 MG, 5 MG, 20 MG) generic QL
PAGE 41 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
PA
OLANZAPINE (15 MG TAB RAPDIS, 10 MG VIAL) generic QL
OLANZAPINE (20 MG, 10 MG, 5 MG, 2.5 MG, 7.5 MG, 15MG)
generic QL
PALIPERIDONE (9 MG ER 24, 6 MG ER 24, 1.5 MG ER24, 3 MG ER 24)
generic
QUETIAPINE FUMARATE (200 MG, 50 MG, 400 MG, 25MG, 300 MG, 100 MG)
generic QL
RISPERDAL CONSTA (25 MG, 12.5 MG, 50 MG, 37.5MG)risperidone microspheres
BRAND PA
RISPERIDONE (1 MG TAB RAPDIS, 2 MG TABLET, 4 MGTAB RAPDIS, 4 MG TABLET, 0.25 MG TABLET, 1 MG/MLSOLUTION, 2 MG TAB RAPDIS, 0.25 MG TAB RAPDIS, 3MG TAB RAPDIS, 0.5 MG TAB RAPDIS, 1 MG TABLET, 3MG TABLET, 0.5 MG TABLET)
generic
SEROQUEL XR (200 MG, 150 MG, 400 MG, 300 MG)quetiapine fumarate
BRAND
QL
C
dosage <150mg/daybeyond initial 30 dayswill require PA forthosebetween 13-64yrs ofage
SEROQUEL XR 50 MG TABLETquetiapine fumarate
BRAND
QL
C
dosage <150mg/daybeyond initial 30 dayswill require PA forthosebetween 13-64yrs ofage
SEROQUEL XR SAMPLE KITquetiapine fumarate
BRAND
ZIPRASIDONE HCL (80 MG, 60 MG, 20 MG, 40 MG) generic QL
TREATMENT-RESISTANT
CLOZAPINE (50 MG TABLET, 12.5 MG TAB RAPDIS, 200MG TABLET, 25 MG TABLET, 100 MG TABLET, 150 MGTAB RAPDIS, 25 MG TAB RAPDIS, 200 MG TABRAPDIS, 100 MG TAB RAPDIS)
generic
ANTIVIRALS
ANTI-CYTOMEGALOVIRUS (CMV) AGENTS
cidofovir 75 mg/ml vial generic
PAGE 42 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
foscarnet sodium 24 mg/ml infus. btl generic
ganciclovir sodium 500 mg vial generic
VALCYTE (450 MG TABLET, 50 MG/ML SOLUTION)valganciclovir hcl
BRAND
valganciclovir hcl 450 mg tablet generic
ANTI-HEPATITIS B (HBV) AGENTS
adefovir dipivoxil 10 mg tablet generic
BARACLUDE 0.05 MG/ML SOLUTIONentecavir
BRAND S Specialty Drug
ENTECAVIR (0.5 MG, 1 MG) generic QL
EPIVIR HBV 25 MG/5 ML SOLNlamivudine
BRAND
lamivudine 100 mg tablet generic
TYZEKA 600 MG TABLETtelbivudine
BRAND
ANTI-HEPATITIS C (HCV) AGENTS
HARVONI 90-400 MG TABLETledipasvir/sofosbuvir
BRAND
QL
PA
S Specialty Drug
INCIVEK 375 MG TABLETtelaprevir
BRANDPA
S Specialty Drug
INFERGEN (15 MCG/0.5 ML, 9 MCG/0.3 ML)interferon alfacon-1
BRANDPA
S Specialty Drug
INTRON A (50 UNITS VIL, 6 UNIT/ML VL, 10 UNIT/ML, 18UNITS VIL, 10 UNITS VIL)interferon alfa-2b,recomb.
BRAND
MODERIBA 200 MG TABLETribavirin
BRANDPA
S Specialty Drug
PEGASYS (180 MCG/ML VIAL, 180 MCG/0.5 MLSYRINGE)peginterferon alfa-2a
BRANDPA
S Specialty Drug
PEGASYS PROCLICK (180, 135)peginterferon alfa-2a
BRANDPA
S Specialty Drug
RIBASPHERE (600 MG TABLET, 400 MG TABLET, 200MG TABLET, 200 MG CAPSULE)ribavirin
BRANDPA
S Specialty Drug
PAGE 43 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
RIBASPHERE RIBAPAK (200-400 MG, 600-600 MG, 600-400 MG, 400-400 MG)ribavirin
BRANDPA
S Specialty Drug
RIBAVIRIN (200 MG CAPSULE, 200 MG TABLET) genericPA
S Specialty Drug
SOVALDI 400 MG TABLETsofosbuvir
BRAND
QL
PA
S Specialty Drug
TECHNIVIE DOSE PACKombitasvir/paritaprevir/ritonavir
BRAND
QL
PA
S Specialty Drug
VICTRELIS 200 MG CAPSULEboceprevir
BRANDPA
S Specialty Drug
VIEKIRA PAKombitasvir/paritaprevir/ritonavir/dasabuvir sodium
BRAND
QL
PA
S Specialty Drug
ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)
ISENTRESS (100 MG POWDER PACKET, 25 MGTABLET CHEW, 400 MG TABLET, 100 MG TABLETCHEW)raltegravir potassium
BRAND PA
STRIBILD TABLETelvitegravir/cobicistat/emtricitabine/tenofovir
BRAND
TIVICAY 50 MG TABLETdolutegravir sodium
BRAND
ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)
ATRIPLA TABLETefavirenz/emtricitabine/tenofovir disoproxil fumarate
BRAND
COMPLERA TABLETemtricitabine/rilpivirine hcl/tenofovir disoproxil fumarate
BRAND
EDURANT 25 MG TABLETrilpivirine hcl
BRAND
INTELENCE (25 MG, 200 MG, 100 MG)etravirine
BRAND
NEVIRAPINE (100 MG TAB ER 24H, 50 MG/5 ML ORALSUSP, 200 MG TABLET, 400 MG TAB ER 24H)
generic
RESCRIPTOR (100 MG, 200 MG) BRAND
PAGE 44 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
delavirdine mesylate
SUSTIVA (200 MG CAPSULE, 600 MG TABLET, 50 MGCAPSULE)efavirenz
BRAND
VIRAMUNE XR (400 MG, 100 MG)nevirapine
BRAND
ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)
abacavir sulfate 300 mg tablet generic
abacavir/lamivudine/zidovudine 150-300mg tablet generic
DIDANOSINE (250 MG, 400 MG, 200 MG, 125 MG) generic
EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE)emtricitabine
BRAND
EPIVIR 10 MG/ML ORAL SOLNlamivudine
BRAND
EPZICOM TABLETabacavir sulfate/lamivudine
BRAND
LAMIVUDINE (300 MG TABLET, 10 MG/ML SOLUTION,150 MG TABLET)
generic
lamivudine/zidovudine 150-300mg tablet generic
STAVUDINE (30 MG CAPSULE, 40 MG CAPSULE, 15MG CAPSULE, 20 MG CAPSULE, 1 MG/ML SOLNRECON)
generic
TRUVADA 200 MG-300 MG TABLETemtricitabine/tenofovir disoproxil fumarate
BRAND
VIDEX (2, 4)didanosine
BRAND
VIREAD (POWDER, 300 MG TABLET, 200 MG TABLET,150 MG TABLET, 250 MG TABLET)tenofovir disoproxil fumarate
BRAND
ZIAGEN 20 MG/ML SOLUTIONabacavir sulfate
BRAND
ZIDOVUDINE (10 MG/ML SYRUP, 300 MG TABLET, 100MG CAPSULE)
generic
ANTI-HIV AGENTS, OTHER
FUZEON (90 MG VIAL, CONVENIENCE KIT)enfuvirtide
BRAND
SELZENTRY (300 MG, 150 MG)maraviroc
BRAND PA
ANTI-HIV AGENTS, PROTEASE INHIBITORS
PAGE 45 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE)tipranavir
BRAND
CRIXIVAN (400 MG, 200 MG)indinavir sulfate
BRAND
INVIRASE (500 MG TABLET, 200 MG CAPSULE)saquinavir mesylate
BRAND
KALETRA (100-25 MG TABLET, 400-100/5 ML ORALSOLU, 200-50 MG TABLET)lopinavir/ritonavir
BRAND
LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET)fosamprenavir calcium
BRAND
NORVIR (80 MG/ML SOLUTION, 100 MG TABLET, 100MG SOFTGEL CAP)ritonavir
BRAND
PREZISTA (600 MG TABLET, 100 MG/ML SUSPENSION,150 MG TABLET, 400 MG TABLET, 800 MG TABLET, 75MG TABLET)darunavir ethanolate
BRAND
REYATAZ (200 MG, 100 MG, 300 MG, 150 MG)atazanavir sulfate
BRAND
VIRACEPT (625 MG, 250 MG)nelfinavir mesylate
BRAND
ANTI-INFLUENZA AGENTS
RELENZA 5 MG DISKHALERzanamivir
BRANDQL
C max 10 day supply/fill
rimantadine hcl 100 mg tablet generic
TAMIFLU (45 MG, 30 MG)oseltamivir phosphate
BRAND
TAMIFLU 6 MG/ML SUSPENSIONoseltamivir phosphate
BRAND C 25ml/day
TAMIFLU 75 MG CAPSULEoseltamivir phosphate
BRAND C 20 capsules/180 days
ANTIHERPETIC AGENTS
ACYCLOVIR (200 MG CAPSULE, 400 MG TABLET, 800MG TABLET, 200 MG/5ML ORAL SUSP)
generic
acyclovir 5 % oint. (g) generic C 15gm/fill
ACYCLOVIR SODIUM (500 MG, 50 MG/ML, 1000 MG) generic
FAMCICLOVIR (500 MG, 250 MG, 125 MG) generic
trifluridine 1 % drops generic
PAGE 46 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
VALACYCLOVIR HCL (500 MG, 1000 MG) generic
ZOVIRAX 5% CREAMacyclovir
BRAND C 5gm/fill
ANXIOLYTICS
ANXIOLYTICS, OTHER
BUSPIRONE HCL (5 MG, 30 MG, 7.5 MG, 10 MG, 15 MG) generic
MIDAZOLAM HCL (5 MG/ML(1) VIAL, 2 MG/ML SYRUP, 2MG/2 ML VIAL, 5 MG/ML VIAL, 5 MG/5 ML VIAL, 10 MG/2ML VIAL, 10 MG/10ML VIAL)
generic
MIDAZOLAM HCL/PF (5 MG/ML SYRINGE, 5 MG/MLCARTRIDGE, 5 MG/5 ML VIAL, 2 MG/2 ML CARTRIDGE,10 MG/2 ML VIAL, 2 MG/2 ML VIAL, 10 MG/2 MLSYRINGE, 5 MG/ML(1) VIAL, 2 MG/2 ML SYRINGE)
generic
BENZODIAZEPINES
ALPRAZOLAM (2 MG TAB RAPDIS, 1 MG TABLET, 0.25MG TAB RAPDIS, 0.5 MG TAB RAPDIS, 0.5 MG TAB ER24H, 2 MG TABLET, 3 MG TAB ER 24H, 1 MG TABRAPDIS, 1 MG TAB ER 24H, 0.25 MG TABLET, 2 MGTAB ER 24H, 0.5 MG TABLET)
generic
ALPRAZOLAM 1 MG/ML ORAL CONCalprazolam
BRAND
CHLORDIAZEPOXIDE HCL (25 MG, 5 MG, 10 MG) generic
CLONAZEPAM (0.125 MG TAB RAPDIS, 0.5 MGTABLET, 1 MG TAB RAPDIS, 0.25 MG TAB RAPDIS, 1MG TABLET, 0.5 MG TAB RAPDIS, 2 MG TAB RAPDIS, 2MG TABLET)
generic
CLORAZEPATE DIPOTASSIUM (7.5 MG, 3.75 MG, 15MG)
generic
DIAZEPAM (2 MG TABLET, 10 MG TABLET, 5 MG/5 MLSOLUTION, 5 MG/ML SYRINGE, 5 MG/ML ORAL CONC,5 MG TABLET, 5 MG/ML VIAL)
generic
LORAZEPAM (4 MG/ML SYRINGE, 2 MG/ML SYRINGE,0.5 MG TABLET, 4 MG/ML VIAL, 2 MG/ML VIAL, 1 MGTABLET, 2 MG/ML ORAL CONC, 2 MG TABLET)
generic
LORAZEPAM INTENSOL 2 MG/MLlorazepam
BRAND
OXAZEPAM (10 MG, 15 MG, 30 MG) generic
BIPOLAR AGENTS
MOOD STABILIZERS
PAGE 47 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
LITHIUM CARBONATE (300 MG TABLET ER, 300 MGTABLET, 300 MG CAPSULE, 600 MG CAPSULE, 150 MGCAPSULE, 450 MG TABLET ER)
generic
lithium citrate 8 meq/5 ml solution generic
BLOOD GLUCOSE REGULATORS
ANTIDIABETIC AGENTS
ACARBOSE (50 MG, 25 MG, 100 MG) generic
ACTOPLUS MET XR (30-1,000 MG, 15-1,000 MG)pioglitazone hcl/metformin hcl
BRAND PA
BYDUREON 2 MG PEN INJECTexenatide microspheres
BRANDPA
C 1 unit/7 days
BYDUREON 2 MG VIALexenatide microspheres
BRANDPA
C 1 unit/7 days
BYETTA (5 MCG, 10 MCG)exenatide
BRANDQL
PA
GLIMEPIRIDE (1 MG, 4 MG, 2 MG) generic
GLIPIZIDE (10 MG TAB ER 24, 5 MG TABLET, 10 MGTABLET, 5 MG TAB ER 24, 2.5 MG TAB ER 24)
generic
GLIPIZIDE/METFORMIN HCL (2.5-250 MG, 5 MG-500MG,2.5-500 MG)
generic
GLYBURIDE (2.5 MG, 5 MG, 1.25 MG) generic
GLYBURIDE,MICRONIZED (3 MG, 6 MG, 1.5 MG) generic
GLYBURIDE/METFORMIN HCL (2.5-500 MG, 1.25-250MG, 5 MG-500MG)
generic
INVOKAMET (50-1,000 MG, 50-500 MG, 150-500 MG,150-1,000 MG)canagliflozin/metformin hcl
BRANDQL
C must try metformin for6 months
INVOKANA (100 MG, 300 MG)canagliflozin
BRAND
JANUMET (50-1,000 MG, 50-500 MG)sitagliptin phosphate/metformin hcl
BRANDST
C must try metformin for6 mos
JANUMET XR (50-500 MG, 50-1,000 MG, 100-1,000 MG)sitagliptin phosphate/metformin hcl
BRANDST
C must try metformin for6 mos
JANUVIA (25 MG, 100 MG)sitagliptin phosphate
BRAND ST
PAGE 48 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
C must try metformin for6 mos
JANUVIA 50 MG TABLETsitagliptin phosphate
BRAND
PA
ST
C must try metformin for6 mos
JENTADUETO (2.5 MG-850 MG, 2.5 MG-1000 MG, 2.5MG-500 MG)linagliptin/metformin hcl
BRANDST
C must try metformin for6 mos
METFORMIN HCL (850 MG TABLET, 750 MG TAB ER24H, 1000 MG TABLET, 500 MG TAB ER 24, 500 MGTAB ER 24H)
generic
metformin hcl 500 mg tablet generic GL Male
NATEGLINIDE (120 MG, 60 MG) generic PA
PIOGLITAZONE HCL (30 MG, 15 MG, 45 MG) generic
PIOGLITAZONE HCL/GLIMEPIRIDE (30 MG-4 MG, 30MG-2 MG)
generic
PIOGLITAZONE HCL/METFORMIN HCL (15MG-500MG,15MG-850MG)
generic
REPAGLINIDE (1 MG, 2 MG, 0.5 MG) generic
REPAGLINIDE/METFORMIN HCL (1MG-500MG, 2 MG-500MG)
generic
RIOMET 500 MG/5 ML SOLUTIONmetformin hcl
BRAND
SYMLINPEN 120 PEN INJECTORpramlintide acetate
BRAND PA
SYMLINPEN 60 PEN INJECTORpramlintide acetate
BRAND PA
TOLAZAMIDE (250 MG, 500 MG) generic
tolbutamide 500 mg tablet generic
TRADJENTA 5 MG TABLETlinagliptin
BRANDST
C must try metformin for6 mos
VICTOZA 2-PAK 18 MG/3 ML PENliraglutide
BRANDQL
PA
VICTOZA 3-PAK 18 MG/3 ML PENliraglutide
BRANDQL
PA
PAGE 49 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
GLYCEMIC AGENTS
GLUCAGEN (1 MG HYPOKIT, DIAGNOSTIC 1 MG VIAL,1 MG HYPOKIT 2-PACK)glucagon,human recombinant
BRAND
GLUCAGON 1 MG EMERGENCY KITglucagon,human recombinant
BRAND
glucagon hcl 1 mg vial generic
PROGLYCEM 50 MG/ML ORAL SUSPdiazoxide
BRAND
INSULINS
HUMALOG 200 UNITS/ML KWIKPENinsulin lispro
BRAND
HUMULIN R 500 UNITS/ML VIALinsulin regular, human
BRAND
LANTUS 100 UNITS/ML VIALinsulin glargine,human recombinant analog
BRAND
LANTUS SOLOSTAR 100 UNITS/MLinsulin glargine,human recombinant analog
BRAND
LEVEMIR 100 UNITS/ML VIALinsulin detemir
BRAND
LEVEMIR FLEXPEN 100 UNITS/MLinsulin detemir
BRAND
LEVEMIR FLEXTOUCH 100 UNITS/MLinsulin detemir
BRAND
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS
ANTICOAGULANTS
ACD INJECTION SOLUTIONdextrose-water/sodium citrate/citric acid
BRAND
ACD-A SOLUTIONcitrate dextrose solution
BRAND
argatroban in nacl,iso-osmotic 50 mg/50ml vial generic
citrate phosphate dextros soln 2.63 g/100 solution generic
ENOXAPARIN SODIUM (300MG/3ML VIAL, 150 MG/MLSYRINGE, 120MG/.8ML SYRINGE, 100 MG/MLSYRINGE, 40MG/0.4ML SYRINGE, 30MG/0.3MLSYRINGE, 80MG/0.8ML SYRINGE, 60MG/0.6MLSYRINGE)
generic C PA required if days'supply > or =11 days
FONDAPARINUX SODIUM (10MG/0.8ML, 2.5 MG/0.5,5MG/0.4ML, 7.5MG/0.6)
genericPA
C PA required if days'
PAGE 50 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
supply > or =11 days
S Specialty Drug
HEPARIN 50 UNITS/5 ML (10/ML)heparin sodium,porcine/pf
BRAND
HEPARIN SODIUM,PORCINE (20000/ML VIAL, 10UNIT/ML VIAL, 1000/ML VIAL, 100/ML (1) SYRINGE, 10UNIT/ML SYRINGE, 300/3 ML SYRINGE, 100/ML VIAL,5000/ML VIAL, 200/2 ML SYRINGE, 5000/ML(1)CARTRIDGE, 500/5 ML SYRINGE, 10000/ML VIAL)
generic
HEPARIN SODIUM,PORCINE IN 0.45 % SODIUMCHLORIDE (HEPAR25000/500, HEPAR25000/250)
generic
HEPARIN SODIUM,PORCINE IN 0.9 % SODIUMCHLORIDE (1K/1000 ML IV SOLN, 100/ML KIT, 10UNIT/ML KIT, 6K/1000 ML IV SOLN)
generic
HEPARIN SODIUM,PORCINE IN 0.9 % SODIUMCHLORIDE/PF (2K/1000ML, 1000/500ML)
generic
HEPARIN SODIUM,PORCINE/DEXTROSE 5 % INWATER (25000/250, 20K/500ML, 12500/250, 25000/500)
generic
HEPARIN SODIUM,PORCINE/PF (5000/0.5ML SYRINGE,500/5 ML SYRINGE, 300/3 ML SYRINGE, 100/ML (1)VIAL, 10 UNIT/ML SYRINGE, 100/ML (1) SYRINGE,5000/0.5ML VIAL, 1000/10 ML SYRINGE, 200/2 MLSYRINGE, 1000/ML VIAL, 10 UNIT/ML VIAL, 1 UNIT/MLSYRINGE)
generic
JANTOVEN (7.5 MG, 6 MG, 5 MG, 2.5 MG, 2 MG, 4 MG, 3MG, 1 MG, 10 MG)warfarin sodium
BRAND
MONOJECT PREFILL ADVANCED (500 UNIT/5 ML(100/ML), 50 UNITS/5 ML (10/ML), 30 UNITS/3 ML(10/ML), 300 UNIT/3 ML (100/ML), 1,000 UNIT/10(100/ML), 100 UNIT/10 ML (10/ML))heparin sodium,porcine/pf
BRAND
PRADAXA (75 MG, 150 MG)dabigatran etexilate mesylate
BRAND PA
protamine sulfate 10 mg/ml vial generic
TRICITRASOL 46.7% VIALsodium citrate dihydrate
BRAND
WARFARIN SODIUM (5 MG, 2.5 MG, 7.5 MG, 1 MG, 2MG, 10 MG, 6 MG, 3 MG, 4 MG)
generic
XARELTO (15 MG, 20 MG, 10 MG)rivaroxaban
BRAND
BLOOD FORMATION MODIFIERS
PAGE 51 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
ANAGRELIDE HCL (1 MG, 0.5 MG) generic
LEUKINE (250 MCG, 500 MCG/ML)sargramostim
BRANDPA
S Specialty Drug
MOZOBIL (24 MG/1.2 ML, 20 MG/ML)plerixafor
BRAND
NEULASTA (6 ML SYRINGE, ONPRO 6 ML KIT)pegfilgrastim
BRANDPA
S Specialty Drug
NEUMEGA 5 MG VIALoprelvekin
BRAND S Specialty Drug
PROCRIT (20,000, 10,000, 2,000, 3,000, 40,000, 4,000)epoetin alfa
BRANDPA
S Specialty Drug
PROMACTA (75 MG, 50 MG, 25 MG, 12.5 MG)eltrombopag olamine
BRAND S Specialty Drug
COAGULANTS
ADVATE (801-1,200, 401-800, 200-400, 3,601-4,800,1,201-1,800, 1,801-2,400)antihemophilic factor (fviii) recomb,full length (alb-free)
BRAND S Specialty Drug
ADVATE 1,201-1,800 UNITS VIALantihemophilic factor (fviii) recomb,full length (alb-free)
BRAND S Specialty Drug
ADVATE 1,801-2,400 UNITS VIALantihemophilic factor (fviii) recomb,full length (alb-free)
BRAND S Specialty Drug
ADVATE 200-400 UNITS VIALantihemophilic factor (fviii) recomb,full length (alb-free)
BRAND S Specialty Drug
ADVATE 401-800 UNITS VIALantihemophilic factor (fviii) recomb,full length (alb-free)
BRAND S Specialty Drug
ADVATE 801-1,200 UNITS VIALantihemophilic factor (fviii) recomb,full length (alb-free)
BRAND S Specialty Drug
ALPHANATE (1,500-600, 1,000-400, 250-100, 500-200,2,000-800)antihemophilic factor, human/von willebrand factor,human
BRAND S Specialty Drug
AMINOCAPROIC ACID (250 MG/ML VIAL, 250 MG/MLSOLUTION, 500 MG TABLET)
generic
BEBULIN 200-1,200 UNITS VIALfactor ix complex, prothrombin cplx conc(pcc) no.6, 3-factor
BRAND
BEBULIN VH IMMU 200-1,200 UNITfactor ix complex human
BRAND S Specialty Drug
BENEFIX (3,000 KIT, 2,000 VIAL, 1,000 KIT, 250 KIT,2,000 KIT, 1,000 VIAL, 500 KIT, 250 VIAL, 500 VIAL)factor ix human recombinant
BRAND S Specialty Drug
PAGE 52 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
CORIFACT KITfactor xiii
BRAND
ELOCTATE (1,000, 250, 2,000, 3,000, 500, 1,500, 750)antihemophilic factor (fviii) recombinant, fc fusion protein
BRANDPA
S Specialty Drug
FEIBA NF (651-1,200 VIAL, 500 (NOMINAL), 1,750-3,250VIAL, 1,000 (NOMINAL), 2,500 (NOMINAL), 400-650VIAL)anti-inhibitor coagulant complex
BRAND
FEIBA VH IMMUNO 651-1,200 UNITanti-inhibitor coagulant complex
BRAND
HELIXATE FS (1,000, 250, 500, 2,000)antihemophilic factor viii, human recombinant
BRANDPA
S Specialty Drug
HELIXATE FS 3,000 UNITS VIALantihemophilic factor (fviii) recomb,full length (alb-free)
BRAND S Specialty Drug
HUMATE-P (2,400, 1,200, 600)antihemophilic factor, human/von willebrand factor,human
BRAND S Specialty Drug
IXINITY (1,000, 1,000 -2 VLS, 1,500, 1,500 -2 VLS, 500)factor ix human recombinant, threonine 148
BRAND S Specialty Drug
KOATE-DVI (250 VIAL, 1,000 VIAL, 500 KIT)antihemophilic factor, human
BRAND S Specialty Drug
KOATE-DVI 500 UNITS VIALantihemophilic factor, human
BRANDPA
S Specialty Drug
KOGENATE FS (2,000 UNIT VIAL, 1,000 UNIT-ADAPTER, 2,000 UNIT-ADAPTER, 3,000 UNITS VIAL,250 UNIT VL-BIOSET, 500 UNIT VIAL, 1,000 UNIT-BIOSET, 500 UNIT VL-ADAPTR, 500 UNIT VL-BIOSET,1,000 UNITS VIAL)antihemophilic factor (fviii) recomb,full length (alb-free)
BRANDPA
S Specialty Drug
KOGENATE FS (250 UNIT VIAL, 250 UNIT VL-ADAPTR,2,000 UNIT-BIOSET)antihemophilic factor (fviii) recomb,full length (alb-free)
BRAND S Specialty Drug
MONONINE 1,000 UNITS KITfactor ix
BRAND S Specialty Drug
MONSEL'S FERRIC SUBSULFATE SOLferric subsulfate
BRAND
NOVOEIGHT (250, 2,000, 1,000, 1,500, 500, 3,000)antihemophilic factor viii recombinant, b-domain truncated
BRAND
NOVOSEVEN RT (8 MG, 5 MG, 1 MG, 2 MG)coagulation factor viia (recombinant)
BRAND
PROFILNINE (500, 1,500, 1,000) BRAND PA
PAGE 53 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
factor ix complex, prothrombin cplx conc(pcc) no.4, 3-factor S Specialty Drug
PROFILNINE SD (1,500, 1,000, 500)factor ix complex human
BRANDPA
S Specialty Drug
RECOMBINATE (1,801-2,400, 1,241-1,800)antihemophilic factor viii, human recombinant
BRAND
RECOMBINATE (801-1,240 VL, 401-800 VIAL, 220-400VIAL)antihemophilic factor viii, human recombinant
BRAND S Specialty Drug
RIASTAP VIALfibrinogen
BRAND
tranexamic acid 650 mg tablet generic
TRETTEN 2,500 UNIT VIALfactor xiii a-subunit, recombinant
BRAND
XYNTHA (500, 2,000, 250, 1,000)antihemophilic factor (factor viii) recomb,b-domain deleted
BRAND
XYNTHA SOLOFUSE (500 KIT, 3,000 KIT, 1,000 SYR,500 SYR, 3,000 SYR, 1,000 KIT, 2,000 SYR, 250 SYR,250 KIT, 2,000 KIT)antihemophilic factor (factor viii) recomb,b-domain deleted
BRAND
PLATELET MODIFYING AGENTS
aspirin/dipyridamole 25mg-200mg cpmp 12hr generic
BRILINTA (90 MG, 60 MG)ticagrelor
BRAND
CILOSTAZOL (50 MG, 100 MG) generic
CLOPIDOGREL BISULFATE (75 MG, 300 MG) generic
DIPYRIDAMOLE (75 MG TABLET, 25 MG TABLET, 50MG TABLET, 5 MG/ML VIAL)
generic
EFFIENT (10 MG, 5 MG)prasugrel hcl
BRAND
EPTIFIBATIDE (0.75 MG/ML, 2 MG/ML) generic PA
ZONTIVITY 2.08 MG TABLETvorapaxar sulfate
BRANDQL
PA
CARDIOVASCULAR AGENTS
ALPHA-ADRENERGIC AGONISTS
CLONIDINE (0.1MG/24HR, 0.2MG/24HR, 0.3MG/24HR) generic
CLONIDINE HCL (0.3 MG, 0.2 MG, 0.1 MG) generic
PAGE 54 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
CLONIDINE HCL/PF (1000MCG/10, 5000MCG/10) generic
GUANFACINE HCL (2 MG, 1 MG) generic
METHYLDOPA (500 MG, 250 MG) generic
methyldopate hcl 250 mg/5ml vial generic
MIDODRINE HCL (5 MG, 2.5 MG, 10 MG) generic
ALPHA-ADRENERGIC BLOCKING AGENTS
DIBENZYLINE 10 MG CAPSULEphenoxybenzamine hcl
BRAND
DOXAZOSIN MESYLATE (4 MG, 1 MG, 2 MG, 8 MG) generic
phenoxybenzamine hcl 10 mg capsule generic
phentolamine mesylate 5 mg vial generic
PRAZOSIN HCL (1 MG, 2 MG, 5 MG) generic
RESERPINE (0.1 MG, 0.25 MG) generic
ANGIOTENSIN II RECEPTOR ANTAGONISTS
CANDESARTAN CILEXETIL (4 MG, 32 MG, 16 MG, 8MG)
generic
eprosartan mesylate 600 mg tablet generic
IRBESARTAN (75 MG, 300 MG, 150 MG) generic
LOSARTAN POTASSIUM (50 MG, 100 MG, 25 MG) generic
TELMISARTAN (80 MG, 20 MG, 40 MG) generic
VALSARTAN (80 MG, 320 MG, 40 MG, 160 MG) generic
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS
BENAZEPRIL HCL (20 MG, 5 MG, 40 MG, 10 MG) generic
CAPTOPRIL (50 MG, 25 MG, 100 MG, 12.5 MG) generic
ENALAPRIL MALEATE (5 MG, 20 MG, 2.5 MG, 10 MG) generic
enalaprilat dihydrate 1.25 mg/ml vial generic
FOSINOPRIL SODIUM (40 MG, 20 MG, 10 MG) generic
LISINOPRIL (10 MG, 30 MG, 40 MG, 2.5 MG, 5 MG, 20MG)
generic
MOEXIPRIL HCL (15 MG, 7.5 MG) generic
PERINDOPRIL ERBUMINE (4 MG, 8 MG, 2 MG) generic
QUINAPRIL HCL (5 MG, 10 MG, 40 MG, 20 MG) generic
RAMIPRIL (5 MG, 10 MG, 2.5 MG, 1.25 MG) generic
PAGE 55 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
TRANDOLAPRIL (2 MG, 4 MG, 1 MG) generic
ANTIARRHYTHMICS
ADENOSINE (3 MG/ML SYRINGE, 3 MG/ML VIAL) generic
AMIODARONE HCL (50 MG/ML VIAL, 200 MG TABLET,100 MG TABLET, 50 MG/ML AMPUL, 400 MG TABLET,150 MG/3ML SYRINGE)
generic
FLECAINIDE ACETATE (50 MG, 150 MG, 100 MG) generic
ibutilide fumarate 0.1 mg/ml vial generic
MEXILETINE HCL (150 MG, 200 MG, 250 MG) generic
PACERONE (100 MG, 200 MG, 400 MG)amiodarone hcl
BRAND
PROCAINAMIDE HCL (500 MG/ML, 100 MG/ML) generic
PROPAFENONE HCL (300 MG TABLET, 425 MG CAPER 12H, 225 MG CAP ER 12H, 325 MG CAP ER 12H, 225MG TABLET, 150 MG TABLET)
generic
QUINIDINE GLUCONATE (80 MG/ML VIAL, 324 MGTABLET ER)
generic
QUINIDINE SULFATE (300 MG ER, 300 MG, 200 MG) generic
SORINE (80 MG, 160 MG, 240 MG, 120 MG)sotalol hcl
BRAND
SOTALOL HCL (240 MG, 160 MG, 120 MG, 80 MG) generic
TIKOSYN (500 MCG, 250 MCG, 125 MCG)dofetilide
BRAND
BETA-ADRENERGIC BLOCKING AGENTS
ACEBUTOLOL HCL (400 MG, 200 MG) generic
ATENOLOL (25 MG, 50 MG, 100 MG) generic
BETAXOLOL HCL (20 MG, 10 MG) generic
BISOPROLOL FUMARATE (5 MG, 10 MG) generic
CARVEDILOL (12.5 MG, 25 MG, 6.25 MG, 3.125 MG) generic
esmolol hcl 100mg/10ml vial generic
LABETALOL HCL (100 MG TABLET, 20 MG/4 MLSYRINGE, 5 MG/ML VIAL, 200 MG TABLET, 300 MGTABLET)
generic
METOPROLOL SUCCINATE (25 MG ER, 50 MG ER, 100MG ER, 200 MG ER)
generic
METOPROLOL TARTRATE (5 MG/5 ML SYRINGE, 5MG/5 ML AMPUL, 5 MG/5 ML VIAL, 50 MG TABLET, 25 generic
PAGE 56 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
MG TABLET, 100 MG TABLET)
NADOLOL (20 MG, 80 MG, 40 MG) generic
PINDOLOL (5 MG, 10 MG) generic
PROPRANOLOL HCL (60 MG CAP SA 24H, 80 MGTABLET, 80 MG CAP SA 24H, 60 MG TABLET, 10 MGTABLET, 20 MG/5 ML SOLUTION, 40 MG TABLET, 20MG TABLET, 120 MG CAP SA 24H, 1 MG/ML VIAL, 160MG CAP SA 24H, 40MG/5ML SOLUTION)
generic
TIMOLOL MALEATE (10 MG, 20 MG, 5 MG) generic
CALCIUM CHANNEL BLOCKING AGENTS
AFEDITAB CR (30 MG, 60 MG)nifedipine
BRAND
AMLODIPINE BESYLATE (5 MG, 2.5 MG, 10 MG) generic
CARTIA XT (120 MG, 300 MG, 180 MG, 240 MG)diltiazem hcl
BRAND
DILT-XR (120 MG, 180 MG, 240 MG)diltiazem hcl
BRAND
DILTIAZEM HCL (120 MG CAP ER 12H, 180 MG CAP ER24H, 30 MG TABLET, 120 MG CAP ER 24H, 420MGCAPSULE ER, 60 MG CAP ER 12H, 240 MG TAB ER24H, 5 MG/ML VIAL, 240 MG CAP ER DEG, 240 MG CAPER 24H, 100 MG VIAL PORT, 300 MG CAP ER 24H, 60MG TABLET, 120 MG CAP ER DEG, 240 MG CAPSULEER, 180 MG CAP ER DEG, 300 MG CAPSULE ER, 180MG TAB ER 24H, 180 MG CAPSULE ER, 420MG TAB ER24H, 300 MG TAB ER 24H, 360 MG CAP ER 24H, 90 MGCAP ER 12H, 360 MG CAPSULE ER, 120 MG CAPSULEER, 90 MG TABLET, 360 MG TAB ER 24H, 120 MGTABLET)
generic
FELODIPINE (5 MG ER, 2.5 MG ER, 10 MG ER) generic
ISRADIPINE (2.5 MG, 5 MG) generic
MATZIM LA (180 MG, 300 MG, 360 MG, 240 MG, 420MG)diltiazem hcl
BRAND
NICARDIPINE HCL (25 MG/10ML VIAL, 25 MG/10MLAMPUL, 20 MG CAPSULE, 30 MG CAPSULE)
generic
nicardipine hcl in 0.9% nacl 1 mg/10 ml syringe generic
NIFEDIAC CC 30 MG TABLETnifedipine
BRAND
NIFEDICAL XL (30 MG, 60 MG)nifedipine
BRAND
PAGE 57 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
NIFEDIPINE (60 MG TABLET ER, 30 MG TAB ER 24, 60MG TAB ER 24, 30 MG TABLET ER, 90 MG TAB ER 24,90 MG TABLET ER)
generic
nimodipine 30 mg capsule generic
NISOLDIPINE (25.5 MG ER, 30 MG ER, 8.5MG ER, 40MG ER, 17 MG ER, 20 MG ER, 34 MG ER)
generic
TAZTIA XT (300 MG, 120 MG, 180 MG, 240 MG)diltiazem hcl
BRAND
VERAPAMIL HCL (300 MG CAP24H PCT, 2.5 MG/MLAMPUL, 2.5 MG/ML VIAL, 240 MG CAP24H PEL, 200 MGCAP24H PCT, 2.5 MG/ML SYRINGE, 180 MG TABLETER, 120 MG CAP24H PEL, 40 MG TABLET, 80 MGTABLET, 120 MG TABLET, 120 MG TABLET ER, 240 MGTABLET ER, 180 MG CAP24H PEL, 360 MG CAP24HPEL, 100 MG CAP24H PCT)
generic
CARDIOVASCULAR AGENTS, OTHER
alprostadil 500 mcg/ml vial generic
amiloride/hydrochlorothiazide 5 mg-50 mg tablet generic
AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM (10MG-80MG, 10 MG-20MG, 2.5MG-20MG, 5 MG-20 MG,2.5MG-40MG, 2.5MG-10MG, 5 MG-80 MG, 10 MG-40MG,5 MG-40 MG, 5 MG-10 MG, 10 MG-10MG)
generic
AMLODIPINE BESYLATE/BENAZEPRIL HCL (2.5MG-10MG, 10 MG-40MG, 5 MG-40 MG, 10 MG-20MG, 5 MG-10 MG, 5 MG-20 MG)
generic
AMLODIPINE BESYLATE/VALSARTAN (10MG-160MG,5MG-320MG, 10MG-320MG)
generic QL
AMLODIPINEBESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDE (5-160-25MG, 10MG-160MG, 5-160-12.5, 10-320-25, 10-160-25)
generic
amlodipine/valsartan 5 mg-160mg tablet generic
ATENOLOL/CHLORTHALIDONE (50 MG-25MG, 100MG-25MG)
generic
BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE (20-12.5MG, 10-12.5MG, 20-25MG, 5-6.25MG)
generic
BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE(10-6.25MG, 2.5-6.25MG, 5-6.25MG)
generic
CANDESARTAN CILEXETIL/HYDROCHLOROTHIAZIDE(16-12.5MG, 32-12.5MG, 32MG-25MG)
generic
CAPTOPRIL/HYDROCHLOROTHIAZIDE (25 MG-25MG,25 MG-15MG, 50 MG-15MG, 50 MG-25MG)
generic
PAGE 58 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
cardioplegic solution no.1 k+=16meq/l plst bg pf generic
CLORPRES (0.1-15, 0.2-15)clonidine hcl/chlorthalidone
BRAND
CORLANOR (5 MG, 7.5 MG)ivabradine hcl
BRAND QL
DEMSER 250 MG CAPSULEmetyrosine
BRAND
DIGITEK 250 MCG TABLETdigoxin
BRAND
DIGOX (250 MCG, 125 MCG)digoxin
BRAND
DIGOXIN (250 MCG/ML AMPUL, 125 MCG TABLET, 50MCG/ML SOLUTION, 250 MCG TABLET, 250 MCG/MLSYRINGE)
generic
DOBUTAMINE HCL (500MG/40ML, 250MG/20ML) generic
DOBUTAMINE HCL/DEXTROSE 5 % IN WATER(500MG/250, 250MG/250, 500 MG/500, 1000MG/250)
generic
DOPAMINE HCL (200 MG/5ML, 400 MG/5ML,800MG/10ML, 400MG/10ML, 800MG/5ML)
generic
DOPAMINE HCL/DEXTROSE 5 % IN WATER(400MG/0.5L, 200MG/.25L, 800MG/0.5L, 400MG/.25L,800MG/.25L)
generic
ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE(5MG-12.5MG, 10 MG-25MG)
generic
ephedrine sulfate 50 mg/ml vial generic
FOSINOPRIL SODIUM/HYDROCHLOROTHIAZIDE (20-12.5 MG, 10-12.5MG)
generic
IRBESARTAN/HYDROCHLOROTHIAZIDE (300-12.5MG,150-12.5MG)
generic
LISINOPRIL/HYDROCHLOROTHIAZIDE (20-12.5 MG, 10-12.5MG, 20-25MG)
generic
LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE(50-12.5 MG, 100-12.5MG, 100MG-25MG)
generic
MANNITOL (25 VIAL, 20 IV SOLN, 5 IV SOLN, 10 IVSOLN)
generic
METHYLDOPA/HYDROCHLOROTHIAZIDE (250MG-25MG, 250MG-15MG)
generic
METOPROLOL TARTRATE/HYDROCHLOROTHIAZIDE(50 MG-25MG, 100MG-50MG, 100MG-25MG)
generic
milrinone lactate 1 mg/ml vial generic
PAGE 59 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
MILRINONE LACTATE/DEXTROSE 5 % IN WATER(40MG/200ML, 20MG/100ML)
generic
MOEXIPRIL HCL/HYDROCHLOROTHIAZIDE (15-25MG,15-12.5MG, 7.5-12.5MG)
generic
NADOLOL/BENDROFLUMETHIAZIDE (40 MG, 80 MG) generic
NOREPINEPHRINE BITARTRATE (1 MG/ML AMPUL, 1MG/ML VIAL)
generic
NOREPINEPHRINE BITARTRATE IN 0.9 % SODIUMCHLORIDE (8 MG/250ML, 4MG/250ML)
generic
NORTHERA (200 MG, 300 MG, 100 MG)droxidopa
BRANDQL
PA
OSMITROL (20%, 15%)mannitol
BRAND
pentoxifylline 400 mg tablet er generic
phenylephrine hcl 10 mg/ml vial generic
PHENYLEPHRINE HCL IN 0.9 % SODIUM CHLORIDE/PF(1 MG/10 ML SYRINGE, 80MG/250ML PLAST. BAG)
generic
phenylephrine hcl in 0.9% nacl 1 mg/10 ml syringe generic
PROPRANOLOL HCL/HYDROCHLOROTHIAZIDE (80,40)
generic
QUINAPRIL HCL/HYDROCHLOROTHIAZIDE (10-12.5MG, 20-12.5 MG, 20-25MG)
generic
spironolact/hydrochlorothiazid 25 mg-25mg tablet generic
TELMISARTAN/AMLODIPINE BESYLATE (80 MG-10MG,40 MG-10MG, 80 MG-5 MG, 40 MG-5 MG)
generic
TELMISARTAN/HYDROCHLOROTHIAZIDE (40-12.5 MG,80-12.5MG, 80 MG-25MG)
generic
TRANDOLAPRIL/VERAPAMIL HCL (1-240MG, 4-240MG,2-240MG, 2 MG-180MG)
generic
TRIAMTERENE/HYDROCHLOROTHIAZIDE (50 MG-25MG CAPSULE, 37.5-25 MG CAPSULE, 75 MG-50MGTABLET, 37.5-25 MG TABLET)
generic
VALSARTAN/HYDROCHLOROTHIAZIDE (160-12.5MG,160-25MG, 320MG-25MG, 80-12.5MG, 320-12.5MG)
generic
DIURETICS, CARBONIC ANHYDRASE INHIBITORS
ACETAZOLAMIDE (125 MG TABLET, 500 MG CAPSULEER, 250 MG TABLET)
generic
acetazolamide sodium 500 mg vial generic
PAGE 60 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
DIURETICS, LOOP
BUMETANIDE (1 MG TABLET, 0.5 MG TABLET, 2 MGTABLET, 0.25 MG/ML VIAL)
generic
ethacrynate sodium 50 mg vial generic
FUROSEMIDE (80 MG TABLET, 20 MG TABLET, 10MG/ML SYRINGE, 40 MG TABLET, 10 MG/MLSOLUTION, 40MG/5ML SOLUTION, 10 MG/ML VIAL)
generic
TORSEMIDE (5 MG TABLET, 20 MG/2 ML VIAL, 10 MGTABLET, 20 MG TABLET, 100 MG TABLET)
generic
DIURETICS, POTASSIUM-SPARING
amiloride hcl 5 mg tablet generic
EPLERENONE (25 MG, 50 MG) generic
SPIRONOLACTONE (50 MG, 100 MG, 25 MG) generic
DIURETICS, THIAZIDE
CHLOROTHIAZIDE (250 MG, 500 MG) generic
chlorothiazide sodium 500 mg vial generic
CHLORTHALIDONE (25 MG, 50 MG) generic
HYDROCHLOROTHIAZIDE (12.5 MG CAPSULE, 50 MGTABLET, 12.5 MG TABLET, 25 MG TABLET)
generic
INDAPAMIDE (2.5 MG, 1.25 MG) generic
methyclothiazide 5 mg tablet generic
METOLAZONE (10 MG, 2.5 MG, 5 MG) generic
DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES
FENOFIBRATE (50 MG CAPSULE, 40 MG TABLET, 54MG TABLET, 160 MG TABLET, 150 MG CAPSULE, 120MG TABLET)
generic
FENOFIBRATE NANOCRYSTALLIZED (145MG, 48 MG) generic
FENOFIBRATE,MICRONIZED (43 MG, 130 MG, 67 MG,134MG, 200 MG)
generic
FENOFIBRIC ACID (35 MG, 105 MG) generic
FENOFIBRIC ACID (CHOLINE) (45 MG, 135 MG) generic
gemfibrozil 600 mg tablet generic
DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS
ATORVASTATIN CALCIUM (20 MG, 40 MG, 80 MG, 10MG)
generic
PAGE 61 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
FLUVASTATIN SODIUM (40 MG CAPSULE, 80 MG TABER 24H, 20 MG CAPSULE)
generic
LOVASTATIN (10 MG, 40 MG, 20 MG) generic
PRAVASTATIN SODIUM (20 MG, 80 MG, 40 MG, 10 MG) generic
SIMVASTATIN (20 MG, 40 MG, 5 MG, 80 MG, 10 MG) generic
DYSLIPIDEMICS, OTHER
CHOLESTYRAMINE (WITH SUGAR) (SUAR) 4 POWDER,SUAR) 4 POWD PACK)
generic
CHOLESTYRAMINE/ASPARTAME (4 POWD PACK, 4POWDER)
generic
COLESTIPOL HCL (5 PACKET, 1 TABLET, 5 RANULES) generic
JUXTAPID (60 MG, 40 MG, 30 MG, 5 MG, 20 MG, 10 MG)lomitapide mesylate
BRANDPA
S Specialty Drug
NIACIN (1000 MG ER, 750 MG ER, 500 MG ER) generic
omega-3 acid ethyl esters 1 g capsule generic
PREVALITE (PACKET, POWDER)cholestyramine/aspartame
BRAND
VASCEPA 1 GM CAPSULEicosapent ethyl
BRAND
ZETIA 10 MG TABLETezetimibe
BRAND PA
VASODILATORS, DIRECT-ACTING ARTERIAL
CORLOPAM 10 MG/ML VIALfenoldopam mesylate
BRAND
HYDRALAZINE HCL (50 MG TABLET, 10 MG TABLET, 25MG TABLET, 20 MG/ML VIAL, 100 MG TABLET)
generic
MINOXIDIL (10 MG, 2.5 MG) generic
VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS
amyl nitrite 0.3 ml ampul generic
ISOSORBIDE DINITRATE (40 MG ER, 5 MG, 10 MG, 20MG, 30 MG)
generic
ISOSORBIDE MONONITRATE (10 MG TABLET, 60 MGTAB ER 24H, 30 MG TAB ER 24H, 20 MG TABLET, 120MG TAB ER 24H)
generic
NITRO-BID 2% OINTMENTnitroglycerin
BRAND
NITRO-TIME (ER 9 MG, ER 6.5 MG, ER 2.5 MG) BRAND
PAGE 62 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
nitroglycerin
NITROGLYCERIN (2.5 MG CAPSULE ER, 0.2MG/HRPATCH TD24, 0.6MG/HR PATCH TD24, 400MCG/SPRSPRAY, 50 MG/10ML VIAL, 9 MG CAPSULE ER,0.4MG/HR PATCH TD24, 6.5 MG CAPSULE ER,0.1MG/HR PATCH TD24)
generic
NITROGLYCERIN/DEXTROSE 5 % IN WATER(50MG/500ML, 100MG/250, 200MG/500, 25MG/250ML,50MG/250ML)
generic
NITROSTAT (0.4 MG, 0.6 MG, 0.3 MG)nitroglycerin
BRAND
CENTRAL NERVOUS SYSTEM AGENTS
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES
DEXEDRINE 10 MG TABLETdextroamphetamine sulfate
BRAND
DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF-ASPARTATE (30MG TABLET, 20 MG TABLET, 10 MG TABLET, 30 MGCAP ER 24H, 7.5 MG TABLET, 12.5 MG TABLET, 15 MGTABLET, 10 MG CAP ER 24H, 20 MG CAP ER 24H, 15MG CAP ER 24H, 5 MG CAP ER 24H, 25 MG CAP ER24H, 5 MG TABLET)
generic
DEXTROAMPHETAMINE SULFATE (15 MG CAPSULEER, 5 MG/5 ML SOLUTION, 5 MG TABLET, 5 MGCAPSULE ER, 10 MG TABLET, 10 MG CAPSULE ER)
generic
methamphetamine hcl 5 mg tablet generic PA
PROCENTRA 5 MG/5 ML SOLUTIONdextroamphetamine sulfate
BRAND
VYVANSE (60 MG, 20 MG, 50 MG, 30 MG, 10 MG, 70MG, 40 MG)lisdexamfetamine dimesylate
BRAND
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES
clonidine hcl 0.1 mg tab er 12h generic
DEXMETHYLPHENIDATE HCL (30 MG CPBP 50-50, 5MG TABLET, 20 MG CPBP 50-50, 15 MG CPBP 50-50, 10MG CPBP 50-50, 40 MG CPBP 50-50, 5 MG CPBP 50-50,10 MG TABLET, 2.5 MG TABLET)
generic
GUANFACINE HCL (1 MG ER, 3 MG ER, 4 MG ER, 2 MGER)
generic
METADATE ER 20 MG TABLETmethylphenidate hcl
BRAND
PAGE 63 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
METHYLPHENIDATE HCL (54 MG TAB ER 24, 10 MGTABLET, 10 MG TABLET ER, 27 MG TAB ER 24, 20 MGCPBP 30-70, 50 MG CPBP 30-70, 5 MG TABLET, 30 MGCPBP 50-50, 10 MG/5 ML SOLUTION, 5 MG/5 MLSOLUTION, 10 MG CPBP 30-70, 5 MG TAB CHEW, 40MG CPBP 50-50, 20 MG TABLET, 20 MG CPBP 50-50,2.5 MG TAB CHEW, 18 MG TAB ER 24, 40 MG CPBP 30-70, 10 MG TAB CHEW, 36 MG TAB ER 24, 60 MG CPBP30-70, 20 MG TABLET ER, 30 MG CPBP 30-70)
generic
STRATTERA (100 MG, 25 MG, 40 MG, 18 MG, 80 MG, 60MG, 10 MG)atomoxetine hcl
BRAND
CENTRAL NERVOUS SYSTEM, OTHER
ALAGESIC LQ ORAL SOLUTIONbutalbital/acetaminophen/caffeine
BRAND QL
atracurium besylate 10 mg/ml vial generic
benzphetamine hcl 50 mg tablet generic PA
butalbital/acetaminophen 50mg-325mg tablet generic
BUTALBITAL/ACETAMINOPHEN/CAFFEINE (50-300-40CAPSULE, 50-325-40 TABLET, 50-325-40 CAPSULE)
generic QL
butalbital/aspirin/caffeine 50-325-40 capsule generic QL
CAPACET CAPSULEbutalbital/acetaminophen/caffeine
BRAND QL
DIETHYLPROPION HCL (75 MG ER, 25 MG) generic PA
ESGIC CAPSULEbutalbital/acetaminophen/caffeine
BRAND QL
MARGESIC CAPSULEbutalbital/acetaminophen/caffeine
BRAND QL
MARTEN-TAB 325-50 TABLETbutalbital/acetaminophen
BRAND
metformin hcl 1000 mg tab er 24 generic
NUEDEXTA 20-10 MG CAPSULEdextromethorphan hbr/quinidine sulfate
BRAND
pancuronium bromide 1 mg/ml vial generic
PHENDIMETRAZINE TARTRATE (35 MG TABLET, 105MG CAPSULE ER)
generic PA
PHENTERMINE HCL (30 MG CAPSULE, 37.5 MGCAPSULE, 15 MG CAPSULE, 37.5 MG TABLET)
generic PA
riluzole 50 mg tablet generic
PAGE 64 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
ROCURONIUM BROMIDE (10 MG/ML VIAL,100MG/10ML SYRINGE, 50 MG/5 ML SYRINGE)
generic
succinylcholine chloride 200mg/10ml syringe generic
TENCON 50-325 MG TABLETbutalbital/acetaminophen
BRAND
TETRABENAZINE (12.5 MG, 25 MG) generic
VECURONIUM BROMIDE (20 MG, 10 MG) generic
XENAZINE (25 MG, 12.5 MG)tetrabenazine
BRAND S Specialty Drug
ZEBUTAL 50-325-40 MG CAPSULEbutalbital/acetaminophen/caffeine
BRAND QL
FIBROMYALGIA AGENTS
DULOXETINE HCL (30 MG, 20 MG) generic
PA
ST
CPA depends onindicaton. 60mg maxdaily
duloxetine hcl 60 mg capsule dr generic
PA
ST
C 2/ day .
LYRICA (50 MG CAPSULE, 100 MG CAPSULE, 300 MGCAPSULE, 225 MG CAPSULE, 150 MG CAPSULE, 200MG CAPSULE, 20 MG/ML ORAL SOLUTION, 75 MGCAPSULE, 25 MG CAPSULE)pregabalin
BRAND PA
SAVELLA (50 MG TABLET, 100 MG TABLET, TITRATIONPACK, 25 MG TABLET, 12.5 MG TABLET)milnacipran hcl
BRAND PA
MULTIPLE SCLEROSIS AGENTS
AMPYRA ER 10 MG TABLETdalfampridine
BRANDPA
S Specialty Drug
AVONEX (30 MCG KT, 30 MCG)interferon beta-1a
BRANDPA
S Specialty Drug
AVONEX ADMIN PACK 30 MCG VLinterferon beta-1a/albumin human
BRANDPA
S Specialty Drug
AVONEX PEN (30 ML, 30 ML KIT)interferon beta-1a
BRANDPA
S Specialty Drug
PAGE 65 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
COPAXONE (20 MG/ML, 40 MG/ML)glatiramer acetate
BRANDPA
S Specialty Drug
EXTAVIA 0.3 MG KITinterferon beta-1b
BRANDPA
S Specialty Drug
GILENYA 0.5 MG CAPSULEfingolimod hcl
BRAND
QL
PA
S Specialty Drug
GLATOPA 20 MG/ML SYRINGEglatiramer acetate
BRANDPA
S Specialty Drug
REBIF (TITRATION PACK, 44 MCG/0.5 ML SYRINGE)interferon beta-1a/albumin human
BRANDPA
S Specialty Drug
REBIF 22 MCG/0.5 ML SYRINGEinterferon beta-1a/albumin human
BRAND S Specialty Drug
REBIF REBIDOSE (44 ML, 22 ML)interferon beta-1a/albumin human
BRAND S Specialty Drug
REBIF REBIDOSE TITRATION PACKinterferon beta-1a/albumin human
BRANDPA
S Specialty Drug
TECFIDERA (DR 240 MG CAPSULE, STARTER PACK,DR 120 MG CAPSULE)dimethyl fumarate
BRANDPA
S Specialty Drug
DENTAL AND ORAL AGENTS
cevimeline hcl 30 mg capsule generic
chlorhexidine gluconate 0.12 % mouthwash generic
DEBACTEROL SOLUTIONsulfuric acid/sulfonated phenol
BRAND
FIRST-MOUTHWASH BLM SUSPENSIONmag hydroxide/alhydroxide/simeth/diphenhydramine/lidocaine
BRAND
KEPIVANCE 6.25 MG VIALpalifermin
BRAND
lidocaine hcl 4 % solution generic
PAROEX 0.12% ORAL RINSEchlorhexidine gluconate
BRAND
PERIOGARD 0.12% ORAL RINSEchlorhexidine gluconate
BRAND
PAGE 66 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
PILOCARPINE HCL (7.5 MG, 5 MG) generic
PRE-ATTACHED LTA KITlidocaine hcl
BRAND
DERMATOLOGICAL AGENTS
8-MOP 10 MG CAPSULEmethoxsalen
BRAND
ABSORICA (30 MG, 20 MG, 10 MG, 40 MG)isotretinoin
BRAND
ACITRETIN (17.5 MG, 10 MG, 25 MG) generic
ADAPALENE (0.1 (GRAM), 0.3 W/PUMP) genericQL
C 45gm/30 days
ADAPALENE (0.3 GEL (GRAM), 0.1 CREAM (G)) generic C 45gm/30 days
adapalene 0.1 % lotion generic C 59gm/30 days
ALCLOMETASONE DIPROPIONATE (0.05 OINT., 0.05CREAM)
generic
ALPHAQUIN HP 4% CREAMoxybenzone/octinoxate/hydroquinone
BRAND
AMCINONIDE (0.1 CREAM (G), 0.1 LOTION, 0.1 OINT.(G))
generic
ammonium lactate 12 % cream (g) generic
AMNESTEEM (10 MG, 20 MG, 40 MG)isotretinoin
BRAND
APEXICON 0.05% OINTMENTdiflorasone diacetate
BRAND
APEXICON E 0.05% CREAMdiflorasone diacetate/emollient base
BRAND
AVAR CLEANSERsulfacetamide sodium/sulfur
BRAND
AVITA 0.025% CREAMtretinoin
BRAND C 20gm/30 days
BENZEPRO (6% FOAMING CLOTHS, 7% CREAMYWASH)benzoyl peroxide microspheres
BRAND
BENZOYL PEROXIDE (5 % GEL (GRAM), 7 %CLEANSER, 5 % GEL ALCOHL, 9.8 % FOAM, 5.3%FOAM)
generic
BETAMETHASONE DIPROPIONATE (0.05 LOTION, 0.05GEL (GRAM), 0.05 CREAM (G), 0.05 OINT. (G))
generic
PAGE 67 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
BETAMETHASONE DIPROPIONATE/PROPYLENEGLYCOL (0.05 CREAM (G), 0.05 OINT. (G), 0.05 LOTION)
generic
BETAMETHASONE VALERATE (0.1 CREAM (G), 0.1LOTION, 0.12 FOAM, 0.1 OINT. (G))
generic
BP 10-1 WASHsulfacetamide sodium/sulfur
BRAND
BP CLEANSING WASHsulfacetamide sodium/sulfur/urea
BRAND
BP-50% UREA EMULSIONurea/lactic acid/zinc undecylenate
BRAND
BPO (8% GEL, 4% GEL, 3% FOAMING CLOTHS, 9%FOAMING CLOTHS, 6% FOAMING CLOTHS)benzoyl peroxide
BRAND
CALCIPOTRIENE (0.005 CREAM (G), 0.005 OINT. (G),0.005 SOLUTION)
generic
calcipotriene/betamethasone 0.005-.064 oint. (g) generic
CALCITRENE 0.005% OINTMENTcalcipotriene
BRAND
calcitriol 3 mcg/g oint. (g) generic
CARB-O-PHILIC (GEL, CREAM)urea
BRAND
CEM-UREA 45% PRE-FILLED APPLurea
BRAND
CLARAVIS (40 MG, 30 MG, 20 MG, 10 MG)isotretinoin
BRAND
CLARIS CLARIFYING WASHsulfacetamide sodium/sulfur/urea
BRAND
CLINDACIN ETZ 1% PLEDGETclindamycin phosphate
BRAND
CLINDACIN P 1% PLEDGETSclindamycin phosphate
BRAND
CLINDAMYCIN PHOSPHATE (1 FOAM, 1 LOTION, 1MED. SWAB, 1 GEL (GRAM), 1 SOLUTION)
generic
CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE (1%-5 %, 1.2(1)%-5%)
generic
CLOBETASOL PROPIONATE (0.05 SOLUTION, 0.05LOTION, 0.05 SHAMPOO, 0.05 SPRAY, 0.05 CREAM (G),0.05 FOAM, 0.05 OINT. (G), 0.05 GEL (GRAM))
generic
CLOBETASOL PROPIONATE/EMOLLIENT BASE (0.05FOAM, 0.05 CREAM (G))
generic
PAGE 68 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
CLODAN 0.05% SHAMPOOclobetasol propionate
BRAND
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE (1-0.05 LOTION, 1 -0.05 CREAM (G))
generic
cocaine hcl 4 % solution generic
CORMAX 0.05% SOLUTIONclobetasol propionate
BRAND
DERMAZENE CREAMhydrocortisone/iodoquinol
BRAND
DESONIDE (0.05 LOTION, 0.05 CREAM (G), 0.05 OINT.(G))
generic
DESOXIMETASONE (0.05 CREAM (G), 0.25 OINT. (G),0.25 CREAM (G), 0.05 GEL (GRAM), 0.05 OINT. (G))
generic
DICLOFENAC SODIUM (1.5 DROPS, 3 GEL (GRAM)) generic
DIFLORASONE DIACETATE (0.05 OINT., 0.05 CREAM) generic
DRITHOCREME HP 1% CREAManthralin
BRAND
DRYSOL (DAB-O-MATIC, )aluminum chloride
BRAND
ERY 2% PADSerythromycin base/ethyl alcohol
BRAND
ERYGEL 2% GELerythromycin base/ethyl alcohol
BRAND
ERYTHROMYCIN BASE/ETHYL ALCOHOL (2 MED.SWAB, 2 SOLUTION, 2 GEL (GRAM))
generic
erythromycin/benzoyl peroxide 3 %-5 % gel (gram) generic
ethyl chloride 100 % spray generic
FLUOCINOLONE ACETONIDE (0.025 OINT. (G), 0.01CREAM (G), 0.025 CREAM (G), 0.01 OIL, 0.01SOLUTION)
generic
fluocinolone/shower cap 0.01 % oil generic
FLUOCINONIDE (0.05 GEL (GRAM), 0.05 SOLUTION, 0.1CREAM (G), 0.05 CREAM (G), 0.05 OINT. (G))
generic
fluocinonide/emollient base 0.05 % cream (g) generic
FLUTICASONE PROPIONATE (0.005 OINT. (G), 0.05LOTION, 0.05 CREAM (G))
generic
FORMA-RAY 20% SOLUTIONformaldehyde
BRAND
GENTAMICIN SULFATE (0.1 OINT., 0.1 CREAM) generic
PAGE 69 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
GLYDO 2% JELLY SYRINGElidocaine hcl
BRAND
HALOBETASOL PROPIONATE (0.05 OINT., 0.05CREAM)
generic
HALONATE COMBO PACKhalobetasol propionate/ammonium lactate
BRAND
HALONATE PAC COMBO PACKhalobetasol propionate/ammonium lactate
BRAND
hc/mineral oil/petrolat,wht 1 % oint. (g) generic
HYDROCORTISONE (2.5 LOTION, 2.5 CREAM (G), 1CREAM (G), 2.5 OINT. (G))
generic
hydrocortisone acetate/aloe v 2 % gel (gram) generic
HYDROCORTISONE ACETATE/LIDOCAINE HCL/ALOEVERA (2 %-2 % KIT, 0.55%-2.8% GEL W/APPL, 2.5-3%(7G) KIT)
generic
HYDROCORTISONE ACETATE/PRAMOXINE HCL (1 %-1% CREAM/APPL, 2.5 %-1 % CREAM/APPL, 2.5 %-1 %CREAM (G), 2.5-1%(4G) CREAM/APPL)
generic
HYDROCORTISONEACETATE/PRAMOXINE/EMOLLIENT/PRAMOXINECOMB#1 (2.5%-1%-1%, 2.5-1%(4G))
generic
HYDROCORTISONE BUTYRATE (0.1 OINT. (G), 0.1SOLUTION, 0.1 CREAM (G))
generic
hydrocortisone butyrate/emoll 0.1 % cream (g) generic
HYDROCORTISONE VALERATE (0.2 CREAM, 0.2 OINT.) generic
hydrocortisone/iodoquinol 1 %-1 % cream (g) generic
hydroquinone 4 % cream (g) generic
hydroquinone microspheres 4 % crm er (g) generic
HYPERCARE 20% SOLUTIONaluminum chloride
BRAND
imiquimod 5 % cream pack generic
LACLOTION 12% LOTIONammonium lactate
BRAND
LATRIX 50% TOPICAL SUSPENSIONurea/lactic acid/salicylic acid
BRAND
LATRIX XM 45% EMULSIONurea/lactic acid/zinc undecylenate
BRAND
lidocaine 5 % adh. patch generic PA
lidocaine 5 % oint. (g) generic
PAGE 70 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
LIDOCAINE HCL (3 CREAM (G), 2 JEL/PF APP, 3LOTION, 2 JEL (ML))
generic
LIDOCAINE HCL/HYDROCORTISONE ACETATE (3 %-0.5 % KIT, 3%-1%(7 G) KIT, 3 %-0.5 % CREAM (G), 3 %-0.5 % CREAM/APPL)
generic
LIDOCAINE/PRILOCAINE (2.5 CREAM (G), 2.5 KIT) generic
LINDANE (1 LOTION, 1 SHAMPOO) generic
ST
C
60ml/fill; must trypermethrin andpiperonylbutoxide/pyrethrins
LORENZA 4%-1% PATCHlidocaine/menthol
BRAND
LUSTRA-ULTRA 4% CREAMvitamin a/vitamin e/avobenzone/octinoxate/hydroquinone
BRAND
mafenide acetate 50 g packet generic
MELPAQUE HP 4% CREAMhydroquinone/ferric oxide
BRAND
MELQUIN HP 4% CREAMhydroquinone
BRAND
MELQUIN-3 SOLUTIONhydroquinone
BRAND
METRONIDAZOLE (0.75 GEL (GRAM), 0.75 CREAM (G),1 GEL W/PUMP, 0.75 LOTION, 1 GEL (GRAM))
generic
MOMETASONE FUROATE (0.1 CREAM (G), 0.1 OINT.(G), 0.1 SOLUTION)
generic
mupirocin 2 % oint. (g) generic
mupirocin calcium 2 % cream (g) generic
MYORISAN (10 MG, 30 MG, 20 MG, 40 MG)isotretinoin
BRAND
NEUAC GELclindamycin phosphate/benzoyl peroxide
BRAND
NU-DERM (BLENDER, CLEAR)hydroquinone
BRAND
NUQUIN HP (GEL, CREAM)dioxybenzone/padimate o/hydroquinone
BRAND
OBAGI ELASTIDERM SKIN 4% CREAMhydroquinone
BRAND
OXSORALEN-ULTRA 10 MG CAPmethoxsalen, rapid
BRAND
PAGE 71 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
PAIN RELIEF 5%-1% PATCHlidocaine hcl/menthol
BRAND
permethrin 5 % cream (g) generic C 120ml/fill
podofilox 0.5 % solution generic
PR BENZOYL PEROXIDE 7% WASHbenzoyl peroxide microspheres
BRAND
PR CREAM KITprotectives combination no.2/ceramides 1,3,6-11
BRAND
PRAMCORT 1% CREAMhydrocortisone acetate/pramoxine hcl
BRAND
PREDNICARBATE (0.1 CREAM, 0.1 OINT.) generic
REA LO 39 CREAMurea
BRAND
REA LO 40 (40 CM, 40 TION)urea
BRAND
RECTIV 0.4% OINTMENTnitroglycerin
BRAND
REGRANEX 0.01% GELbecaplermin
BRAND
RELADOR PAK 2.5-2.5% CRM-DRESSlidocaine/prilocaine
BRAND
RELADOR PAK PLUS 2.5%-2.5%lidocaine/prilocaine
BRAND
REMEVEN 50% CREAMurea
BRAND
ROSADAN (GEL, CREAM)metronidazole
BRAND
ROSULA 10%-5% CLOTHSsulfacetamide sodium/sulfur
BRAND
SALACYN (CREAM, LOTION)salicylic acid
BRAND
SALICYLIC ACID (6 CREAM (G), 28.5 LIQ-FILM, 6 GEL(GRAM), 6 SHAMPOO, 27.5 LIQ-FILM, 6 CRM ER (G), 26LIQUID, 6 LOTION ER, 6 LOTION)
generic
salicylic acid/ammon lact/aloe 6 % foam generic
SALICYLIC ACID/CERAMIDES 1,3,6-11 (6 KIT CLCMER,6 COMBO. PKG)
generic
SALVAX 6% FOAMsalicylic acid
BRAND
PAGE 72 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
SANTYL OINTMENTcollagenase clostridium histolyticum
BRAND
SCALACORT 2% LOTIONhydrocortisone
BRAND
SE 10-5 SS CREAMsulfacetamide sodium/sulfur/witch hazel
BRAND
SE BPO 7% WASHbenzoyl peroxide microspheres
BRAND
SEB-PREV 10% WASHsulfacetamide sodium
BRAND
SELENIUM SULFIDE (2.5 SUSPENSION, 2.5 LOTION,2.25 SHAMPOO)
generic
SILVER NITRATE (50 SOLUTION, 10 OINT. (G), 10SOLUTION, 0.5 SOLUTION, 25 SOLUTION)
generic
silver nitrate applicator 75%-25% stick (ea) generic
silver sulfadiazine 1 % cream (g) generic
spinosad 0.9 % suspension generic
ST
C
1420ml/fill; must trypermethrin andpiperonyl butoxide/pyrethrins andmalathion
SS 10-2 CLEANSERsulfacetamide sodium/sulfur
BRAND
SSD 1% CREAMsilver sulfadiazine
BRAND
SSS 10-5 (FOAM, CREAM)sulfacetamide sodium/sulfur
BRAND
sulfacetamide sod/sulfur/urea 10%-5%-10% cleanser generic
SULFACETAMIDE SODIUM (10 SUSPENSION, 10CLNSGEL ER, 10 SHAMPOO, 10 CLEANSER)
generic
SULFACETAMIDE SODIUM/SULFUR (10 %-4 % MED.PAD, 8 %-4 % SUSPENSION, 10 %-5 % MED. PAD,9.8%-4.8% CLEANSER, 9 %-4.5 % CLEANSER, 10-5%(W/W) LOTION, 10-5%(W/V) LOTION, 10-5%(W/W)CREAM (G), 10-5%(W/W) CLEANSER, 10-5%(W/W)SUSPENSION, 9 %-4 % CLEANSER, 10 %-2 %CLEANSER, 10 %-5 % FOAM)
generic
sulfacetamide/sulfur/cleansr23 9 %-4.5 % kit generic
SULFACLEANSE 8-4 SUSPENSIONsulfacetamide sodium/sulfur
BRAND
TACROLIMUS (0.1, 0.03) generic QL
PAGE 73 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
PA
TAZORAC (0.05% CREAM, 0.1% GEL, 0.05% GEL, 0.1%CREAM)tazarotene
BRAND
THERMAZENE 1% CREAMsilver sulfadiazine
BRAND
TRETINOIN (0.025 GEL (GRAM), 0.05 GEL (GRAM),0.025 CREAM (G), 0.01 GEL (GRAM))
generic QL
TRETINOIN (0.05, 0.1) generic QL
TRETINOIN MICROSPHERES (0.1 (GRAM), 0.04W/PUMP, 0.1 W/PUMP, 0.04 (GRAM))
generic QL
TRI-CHLOR 80% SOLUTIONtrichloroacetic acid
BRAND
TRIAMCINOLONE ACETONIDE (0.5 % OINT. (G), 0.1 %LOTION, 0.025 % CREAM (G), 0.5 % CREAM (G), 0.1 %OINT. (G), 0.1 % CREAM (G), 0.147MG/G AEROSOL,0.025 % OINT. (G), 0.025 % LOTION)
generic
TRIANEX 0.05% OINTMENTtriamcinolone acetonide
BRAND
TRIDERM 0.1% CREAMtriamcinolone acetonide
BRAND
UMECTA 40% MOUSSEurea
BRAND
UREA (35 FOAM, 45 LOTION, 45 GEL (ML), 45 CREAM(G), 40 LOTION, 39 CREAM (G), 50 SOL/PF APP, 40 GEL(ML), 40 CREAM (G), 40 NL FM SUSP, 50 CREAM (G))
generic
urea/hyaluronate sodium 40%-0.2% kit generic
urea/lactic ac/zn undecylenate 50 % emulsn(g) generic
urea/lactic acid/salicylic ac 50 % suspension generic
VASHE WOUND THERAPY SOLUTIONsodium chloride irrigating solution/hypochlorous acid
BRAND
VASOLEX OINTMENTtrypsin/balsam peru/castor oil
BRAND
VIRTI-SULF EMOLLIENT CREAMsulfacetamide sodium/sulfur
BRAND
X-VIATE (CREAM, LOTION, GEL)urea
BRAND
ZENCIA WASHsulfacetamide sodium/sulfur
BRAND
PAGE 74 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
ENZYME REPLACEMENT/MODIFIERS
ALDURAZYME 2.9 MG/5 ML VIALlaronidase
BRAND
BUPHENYL 500 MG TABLETsodium phenylbutyrate
BRAND
CREON (12,000, 36,000, 24,000, 6,000, 3,000)lipase/protease/amylase
BRAND
CYSTADANE POWDERbetaine
BRAND
CYSTAGON (150 MG, 50 MG)cysteamine bitartrate
BRAND S Specialty Drug
ELAPRASE 6 MG/3 ML VIALidursulfase
BRAND
ELELYSO 200 UNITS VIALtaliglucerase alfa
BRAND
FABRAZYME (35 MG, 5 MG)agalsidase beta
BRAND
KUVAN (100 MG TABLET, 100 MG POWDER PACKET,500 MG POWDER PACKET)sapropterin dihydrochloride
BRANDPA
S Specialty Drug
LUMIZYME 50 MG VIALalglucosidase alfa
BRAND
MYOZYME 50 MG VIALalglucosidase alfa
BRAND
NAGLAZYME 5 MG/5 ML VIALgalsulfase
BRAND
ORFADIN (5 MG, 2 MG, 10 MG)nitisinone
BRAND
RAVICTI 1.1 GRAM/ML LIQUIDglycerol phenylbutyrate
BRAND
sodium phenylbutyrate 0.94 g/g powder generic
STRENSIQ (18 MG/0.45 ML, 28 MG/0.7 ML, 80 MG/0.8ML, 40 MG/ML)asfotase alfa
BRANDPA
S Specialty Drug
SUCRAID 8,500 UNITS/ML SOLNsacrosidase
BRAND S Specialty Drug
VPRIV 400 UNITS VIALvelaglucerase alfa
BRAND
ZAVESCA 100 MG CAPSULEmiglustat
BRAND S Specialty Drug
PAGE 75 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
GASTROINTESTINAL AGENTS
ANTISPASMODICS, GASTROINTESTINAL
ANASPAZ 0.125 MG TABLET ODThyoscyamine sulfate
BRAND
ATROPINE SULFATE (1 MG/ML VIAL, 0.4 MG/ML VIAL,0.1 MG/ML DISP SYRIN, 0.05MG/ML SYRINGE, 0.1MG/ML SYRINGE)
generic
B-DONNA TABLETphenobarbital/hyoscyamine sulf/atropine sulf/scopolaminehb
BRAND
chlordiazepoxide/clidinium br 5 mg-2.5mg capsule generic
DICYCLOMINE HCL (10 MG CAPSULE, 10 MG/5 MLSOLUTION, 20 MG TABLET)
generic
ED-SPAZ 0.125 MG ODThyoscyamine sulfate
BRAND
GLYCOPYRROLATE (1 MG/5 ML SYRINGE, 0.2 MG/MLVIAL, 0.6MG/3ML SYRINGE, 0.4MG/2ML SYRINGE, 1MG TABLET, 2 MG TABLET)
generic
HYOSCYAMINE SULFATE (125MCG/5ML ELIXIR,0.125MG/ML DROPS, 0.125 MG TABLET, 0.375 MG TABER 12H, 0.125 MG TAB RAPDIS)
generic
HYOSYNE (125 MCG/5 ML ELIXIR, 0.125 MG/ML DROP)hyoscyamine sulfate
BRAND
ME-PB-HYOS TABLETphenobarbital/hyoscyamine sulf/atropine sulf/scopolaminehb
BRAND
OSCIMIN (0.125 MG TABLET, 0.125 MG ODT)hyoscyamine sulfate
BRAND
OSCIMIN SL 0.125 MG TABLEThyoscyamine sulfate
BRAND
OSCIMIN SR 0.375 MG TABLEThyoscyamine sulfate
BRAND
SYMAX FASTABS 0.125 MG TABLEThyoscyamine sulfate
BRAND
SYMAX-SL 0.125 MG TABLET SLhyoscyamine sulfate
BRAND
SYMAX-SR 0.375 MG TABLEThyoscyamine sulfate
BRAND
GASTROINTESTINAL AGENTS, OTHER
PAGE 76 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
CHENODAL 250 MG TABLETchenodiol
BRAND
cromolyn sodium 20 mg/ml oral conc generic
dexpanthenol 250 mg/ml vial generic
DIPHENOXYLATE HCL/ATROPINE SULFATE (2.5-.025MG TABLET, 2.5-.025/5 LIQUID)
generic
GASTROCROM 100 MG/5 ML CONCcromolyn sodium
BRAND
lansoprazole/amoxiciln/clarith 30-500-500 combo. pkg generic
opium tincture 10 mg/ml tincture generic
paregoric 2 mg/5 ml liquid generic
RELISTOR (12 MG/0.6 ML KIT, 12 MG/0.6 ML VIAL, 12MG/0.6 ML SYRINGE, 8 MG/0.4 ML SYRINGE)methylnaltrexone bromide
BRAND
URSODIOL (250 MG TABLET, 300 MG CAPSULE, 500MG TABLET)
generic
VSL#3 DS PACKETlactobacillus combination no.2/s.thermophl/bif cmb no.1
BRAND
HISTAMINE2 (H2) RECEPTOR ANTAGONISTS
CIMETIDINE (300 MG, 800 MG, 400 MG) generic
cimetidine hcl 300 mg/5ml solution generic
FAMOTIDINE (40MG/5ML ORAL SUSP, 10 MG/ML VIAL,40 MG TABLET)
generic
famotidine/pf 20 mg/2 ml vial generic
NIZATIDINE (150MG/10ML SOLUTION, 300 MGCAPSULE, 150 MG CAPSULE)
generic
RANITIDINE HCL (25 MG/ML VIAL, 150 MG CAPSULE,50 MG/2 ML VIAL, 300 MG TABLET, 300 MG CAPSULE,150 MG TABLET, 15 MG/ML SYRUP)
generic
IRRITABLE BOWEL SYNDROME AGENTS
ALOSETRON HCL (0.5 MG, 1 MG) generic
LINZESS (290 MCG, 145 MCG)linaclotide
BRAND
LOTRONEX (1 MG, 0.5 MG)alosetron hcl
BRAND
LAXATIVES
ENULOSE 10 GM/15 ML SOLUTIONlactulose
BRAND
PAGE 77 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
GAVILYTE-H AND BISACODYL KITbisacodyl/sodium chlor/sodium bicarb/potassium chl/peg3350
BRAND
GENERLAC 10 GM/15 ML SOLUTIONlactulose
BRAND
POLYETHYLENE GLYCOL 3350 (3350 17G POWDPACK, 3350 17G/DOSE POWDER)
generic
PROTECTANTS
CARAFATE 1 GM/10 ML SUSPsucralfate
BRAND
MISOPROSTOL (200 MCG, 100 MCG) generic
sucralfate 1 g tablet generic
PROTON PUMP INHIBITORS
esomeprazole magnesium 20 mg capsule dr generic
esomeprazole magnesium 40 mg capsule dr generic C
must try 3 wks oftherapy within the last12 mos of omeprazole,omeprazole OTC orpantoprazole
ESOMEPRAZOLE SODIUM (20 MG, 40 MG) generic
esomeprazole strontium 49.3 mg capsule dr generic
FIRST-LANSOPRAZOLE 3 MG/MLlansoprazole
BRAND
ST
C
no STEP required if<12 yrs old; must try 3weeks of therapy withinlast 12 months ofomeprazole,omeprazole OTC orpantoprazole
FIRST-OMEPRAZOLE 2 MG/ML SUSPomeprazole
BRAND
ST
C
no PA required if <12yrs old; must try 3weeks of therapy withinlast 12 months ofomeprazole,omeprazole OTC orpantoprazole
lansoprazole 15 mg capsule dr genericPA
ST
lansoprazole 30 mg capsule dr generic
ST
C
must try 3 weeks oftherapy withinthe last 12months of
PAGE 78 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
omeprazole,omeprazole OTC orpantoprazole
OMEPRAZOLE (10 MG, 40 MG, 20 MG) generic
OMEPRAZOLE/SODIUM BICARBONATE (20MG-1.1G,40MG-1.1G)
generic
PA
ST
C
must try 3 weeks oftherapy withinthe last 12months ofomeprazole,omeprazole OTC orpantoprazole
PANTOPRAZOLE SODIUM (20 MG TABLET DR, 40 MGVIAL, 40 MG TABLET DR)
generic
rabeprazole sodium 20 mg tablet dr generic
PA
ST
C
must try 3 weeks oftherapy withinthe last 12months ofomeprazole,omeprazole OTC orpantoprazole
GENITOURINARY AGENTS
ANTISPASMODICS, URINARY
flavoxate hcl 100 mg tablet generic
OXYBUTYNIN CHLORIDE (5 MG/5 ML SYRUP, 10 MGTAB ER 24, 5 MG TABLET, 5 MG TAB ER 24, 15 MG TABER 24)
generic
TOLTERODINE TARTRATE (4 MG CAP ER 24H, 1 MGTABLET, 2 MG TABLET, 2 MG CAP ER 24H)
generic
TROSPIUM CHLORIDE (60 MG CAP ER 24H, 20 MGTABLET)
generic
BENIGN PROSTATIC HYPERTROPHY AGENTS
alfuzosin hcl 10 mg tab er 24h generic
dutasteride 0.5 mg capsule generic QL
dutasteride/tamsulosin hcl 0.5-0.4 mg cpmp 24hr generic
finasteride 5 mg tablet generic
tamsulosin hcl 0.4 mg cap er 24h generic
TERAZOSIN HCL (5 MG, 10 MG, 1 MG, 2 MG) generic
PAGE 79 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
GENITOURINARY AGENTS, OTHER
AMINOACETIC ACID 1.5% IRRIGglycine urologic solution
BRAND
BETHANECHOL CHLORIDE (5 MG, 25 MG, 10 MG, 50MG)
generic
citric acid/sodium citrate 334-500mg solution generic
CUPRIMINE 250 MG CAPSULEpenicillamine
BRAND
CYTRA-2 ORAL SOLUTIONcitric acid/sodium citrate
BRAND
CYTRA-3 SYRUPsodium/potassium/potassium citrate/sodium citrate/cit ac
BRAND
CYTRA-K (ORAL SOLUTION, CRYSTALS PACKET)potassium citrate/citric acid
BRAND
ELMIRON 100 MG CAPSULEpentosan polysulfate sodium
BRAND
FEM PH VAGINAL JELLYacetic acid/oxyquinoline sulfate
BRAND
glycine urologic solution 1.5 % irrig soln generic
HEMABATE 250 MCG/ML AMPULcarboprost tromethamine
BRAND
K-PHOS #2 TABLETsodium phosphate,monobasic/potassiumphosphate,monobasic
BRAND
K-PHOS NEUTRAL TABLETphosphorus #1
BRAND
PHENAZOPYRIDINE HCL (200 MG, 100 MG) generic
PHOSPHA 250 NEUTRAL TABLETphosphorus #1
BRAND
POTASSIUM CITRATE (15 ER, 10 ER, 5 ER) generic
POTASSIUM CITRATE/CITRIC ACID (1100-334/5SOLUTION, 3300-1002 PACKET)
generic
RENACIDIN IRRIGATION SOLNcitric acid/gluconolactone/magnesium carbonate
BRAND
sod/pot/k cit/sod cit/cit acid 500-550/5 solution generic
sodium chloride irrig solution 0.9 % irrig soln generic
TARON-CRYSTALS PACKETpotassium citrate/citric acid
BRAND
TRICITRATES ORAL SOLUTION BRAND
PAGE 80 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
sodium/potassium/potassium citrate/sodium citrate/cit ac
VIRT-PHOS 250 NEUTRAL TABLETphosphorus #1
BRAND
VIRTRATE-2 SOLUTIONcitric acid/sodium citrate
BRAND
VIRTRATE-3 SOLUTIONsodium/potassium/potassium citrate/sodium citrate/cit ac
BRAND
VIRTRATE-K SOLUTIONpotassium citrate/citric acid
BRAND
PHOSPHATE BINDERS
CALCIUM ACETATE (667 MG CAPSULE, 667 MGTABLET)
generic
ELIPHOS 667 MG TABLETcalcium acetate
BRAND
RENVELA (800 MG TABLET, 0.8 GM POWDER PACKET,2.4 GM POWDER PACKET)sevelamer carbonate
BRAND
sevelamer carbonate 800 mg tablet generic
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)
A-HYDROCORT 100 MG VIALhydrocortisone sod succinate
BRAND
A-METHAPRED 40 MG UNIVIALmethylprednisolone sodium succinate
BRAND
betamet acet/betamet na ph 6 mg/ml vial generic
cortisone acetate 25 mg tablet generic
DELTASONE 20 MG TABLETprednisone
BRAND
DEXAMETHASONE (6 MG TABLET, 0.5 MG TABLET, 2MG TABLET, 0.75 MG TABLET, 4 MG TABLET, 1.5 MGTABLET, 0.5 MG/5ML ELIXIR, 1 MG TABLET, 0.5MG/5ML SOLUTION)
generic
DEXAMETHASONE INTENSOL 1MG/1MLdexamethasone
BRAND
DEXAMETHASONE SOD PHOSPHATE (10 MG/ML VIAL,4 MG/ML VIAL, 4 MG/ML SYRINGE)
generic
dexamethasone sod phosphate/pf 10 mg/ml vial generic
fludrocortisone acetate 0.1 mg tablet generic
GRX HICORT 25 MG SUPPOSITORYhydrocortisone acetate
BRAND
PAGE 81 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
HEMMOREX-HC (25 MG, 30 MG)hydrocortisone acetate
BRAND
HEMRIL-30 30 MG SUPPOSITORYhydrocortisone acetate
BRAND
HYDROCORTISONE (5 MG, 10 MG, 20 MG) generic
hydrocortisone acetate 25 mg supp.rect generic C only non-DESI NDCsare covered
hydrocortisone acetate 30 mg supp.rect generic
METHYLPREDNISOLONE (4 MG TABLET, 16 MGTABLET, 8 MG TABLET, 4 MG TAB DS PK, 32 MGTABLET)
generic
METHYLPREDNISOLONE ACETATE (80 MG/ML, 40MG/ML)
generic
METHYLPREDNISOLONE SODIUM SUCCINATE (40 MG,1000 MG, 125 MG)
generic
MILLIPRED DP (5 MG 6-DAY, 5 MG 12-DAY)prednisolone
BRAND
prednisolone 15 mg/5 ml solution generic
PREDNISOLONE SOD PHOSPHATE (5 MG/5 MLSOLUTION, 10 MG TAB RAPDIS, 15 MG TAB RAPDIS,15 MG/5 ML SOLUTION, 30 MG TAB RAPDIS, 25 MG/5ML SOLUTION)
generic
PREDNISONE (2.5 MG TABLET, 5 MG TABLET, 1 MGTABLET, 50 MG TABLET, 5 MG/5 ML SOLUTION, 20 MGTABLET, 10 MG TABLET, 10 MG TAB DS PK, 5 MG TABDS PK)
generic
PREDNISONE 5 MG/ML SOLUTIONprednisone
BRAND
RECTACORT-HC 25 MG SUPPOSITORYhydrocortisone acetate
BRAND
TRIAMCINOLONE ACETONIDE (10 MG/ML, 40 MG/ML) generic
VERIPRED 20 20 MG/5 ML SOLNprednisolone sod phosphate
BRAND
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)
chorionic gonadotropin, human 10000 unit vial generic
cosyntropin 0.25 mg vial generic
desmopressin (nonrefrigerated) 10/spray spray/pump generic
DESMOPRESSIN ACETATE (4MCG/ML AMPUL, 0.1 MGTABLET, 0.2 MG TABLET, 0.1 MG/ML SOLUTION,4MCG/ML VIAL, 10/SPRAY SPRAY/PUMP)
generic
PAGE 82 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
GONAL-F RFF (900, 450, 300)follitropin alfa, recomb
BRAND
GONAL-F RFF REDI-JECT (900, 300, 450)follitropin alfa, recomb
BRAND S Specialty Drug
HP ACTHAR GEL 80 UNIT/ML VIALcorticotropin
BRANDPA
S Specialty Drug
INCRELEX 40 MG/4 ML VIALmecasermin
BRANDPA
S Specialty Drug
NORDITROPIN (5 ML, 15 ML)somatropin
BRANDPA
S Specialty Drug
NORDITROPIN FLEXPRO (10 MG/1.5, 5 MG/1.5, 30MG/3 ML, 15 MG/1.5)somatropin
BRANDPA
S Specialty Drug
NORDITROPIN NORDIFLEX (NORDIFLX 15 MG/1.5,NORDIFLX 10 MG/1.5, NORDIFLEX 5 MG/1.5,NORDIFLEX 30 MG/3)somatropin
BRANDPA
S Specialty Drug
NOVAREL 10,000 UNITS VIALchorionic gonadotropin, human
BRAND
STIMATE 1.5 MG/ML NASAL SPRAYdesmopressin acetate
BRAND S Specialty Drug
vasopressin 20 unit/ml vial generic
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)
ANDROGENS
ANDROGEL (1%(5G) PACKET, 1% PUMP)testosterone
BRAND QL
ANDROGEL (1.62%(1.25G) PCKT, 1.62% PUMP,1.62%(2.5G) PCKT, 1%(2.5G) PACKET)testosterone
BRAND
ANDROXY 10 MG TABLETfluoxymesterone
BRAND S Specialty Drug
DANAZOL (200 MG, 50 MG, 100 MG) generic
METHITEST 10 MG TABLETmethyltestosterone
BRAND
methyltestosterone 10 mg capsule generic GL Male
OXANDROLONE (2.5 MG, 10 MG) generic
TESTOPEL 75 MG PELLETS BRAND
PAGE 83 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
testosterone
TESTOSTERONE (1.25G (1%) MD PMP, 50 MG (1%)PACKET, 25MG(1%) PACKET)
generic QL
testosterone 10 mg (2%) gel md pmp generic PA
TESTOSTERONE CYPIONATE (100 MG/ML, 200 MG/ML) generic
testosterone enanthate 200 mg/ml vial generic
ESTROGENS
ALTAVERA-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
ALYACEN (7-7-7-28, 1-35-28)norethindrone-ethinyl estradiol
BRAND
AMETHIA 0.15-0.03-0.01 MG TABlevonorgestrel/ethinyl estradiol and ethinyl estradiol
BRAND
AMETHIA LO TABLETlevonorgestrel/ethinyl estradiol and ethinyl estradiol
BRAND
AMETHYST 90-20 MCG TABLETlevonorgestrel-ethinyl estradiol
BRAND
APRI 28 DAY TABLETdesogestrel-ethinyl estradiol
BRAND
ARANELLE 28 TABLETnorethindrone-ethinyl estradiol
BRAND
ASHLYNA 0.15-0.03-0.01 MG TABlevonorgestrel/ethinyl estradiol and ethinyl estradiol
BRAND
AUBRA-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
AVIANE-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
AZURETTE 28 DAY TABLETdesogestrel-ethinyl estradiol/ethinyl estradiol
BRAND
BALZIVA 28 TABLETnorethindrone-ethinyl estradiol
BRAND
BEKYREE 28 DAY TABLETdesogestrel-ethinyl estradiol/ethinyl estradiol
BRAND
BLISOVI 24 FE TABLETnorethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
BLISOVI FE (1.5-30, 1-20)norethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
BRIELLYN TABLETnorethindrone-ethinyl estradiol
BRAND
PAGE 84 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
CAMRESE 0.15-0.03-0.01 MG TABlevonorgestrel/ethinyl estradiol and ethinyl estradiol
BRAND
CAMRESE LO TABLETlevonorgestrel/ethinyl estradiol and ethinyl estradiol
BRAND
CAZIANT 28 DAY TABLETdesogestrel-ethinyl estradiol
BRAND
CHATEAL-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
CRYSELLE-28 TABLETnorgestrel-ethinyl estradiol
BRAND
CYCLAFEM (7-7-7-28, 1-35-28)norethindrone-ethinyl estradiol
BRAND
CYRED 28 DAY TABLETdesogestrel-ethinyl estradiol
BRAND
DASETTA (7/7/7-28, 1-35-28)norethindrone-ethinyl estradiol
BRAND
DAYSEE 0.15-0.03-0.01 MG TABlevonorgestrel/ethinyl estradiol and ethinyl estradiol
BRAND
DELYLA-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
desog-e.estradiol/e.estradiol 21-5 tablet generic
desogestrel-ethinyl estradiol 0.15-0.03 tablet generic
ELINEST-28 TABLETnorgestrel-ethinyl estradiol
BRAND
EMOQUETTE 28 DAY TABLETdesogestrel-ethinyl estradiol
BRAND
ENPRESSE-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
ENSKYCE 28 TABLETdesogestrel-ethinyl estradiol
BRAND
ESTARYLLA 0.25-0.035 MG TABLETnorgestimate-ethinyl estradiol
BRAND
ESTRADIOL (.0375MG/24 PATCH TDWK, 0.05MG/24HPATCH TDSW, .075MG/24H PATCH TDWK, 2 MGTABLET, .025MG/24H PATCH TDWK, 0.5 MG TABLET,.025MG/24H PATCH TDSW, 0.06MG/24H PATCH TDWK,0.1MG/24HR PATCH TDWK, 1 MG TABLET, .0375MG/24PATCH TDSW, 0.05MG/24H PATCH TDWK, .075MG/24HPATCH TDSW)
generic
ESTRADIOL VALERATE (40 MG/ML, 20 MG/ML, 10MG/ML)
generic
PAGE 85 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
ESTRADIOL/NORETHINDRONE ACETATE (0.5-0.1MG, 1MG-0.5MG)
generic
ESTROPIPATE (0.75 MG, 3 MG, 1.5 MG) generic
ETHINYL ESTRADIOL/DROSPIRENONE (0.03MG-3MG,0.02-3(24))
generic
FALMINA-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
GIANVI 3 MG-0.02 MG TABLETethinyl estradiol/drospirenone
BRAND
GILDAGIA 0.4 MG-0.035 MG TABnorethindrone-ethinyl estradiol
BRAND
GILDESS (1.5 MG-30 MCG, 1 MG-20 MCG)norethindrone acetate-ethinyl estradiol
BRAND
GILDESS 24 FE 1-0.02 MG TABLETnorethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
GILDESS FE (1-20, 1.5-30)norethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
INTROVALE 0.15-0.03 MG TABLETlevonorgestrel-ethinyl estradiol
BRAND
JINTELI 1 MG-5 MCG TABLETnorethindrone acetate-ethinyl estradiol
BRAND
JOLESSA 0.15 MG-0.03 MG TABLETlevonorgestrel-ethinyl estradiol
BRAND
JUNEL (1 MG-20 MCG, 1.5 MG-30 MCG)norethindrone acetate-ethinyl estradiol
BRAND
JUNEL FE (1.5 MG-30 MCG, 1 MG-20 MCG)norethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
JUNEL FE 24 TABLETnorethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
KAITLIB FE CHEWABLE TABLETnorethindrone-ethinyl estradiol/ferrous fumarate
BRAND
KARIVA 28 DAY TABLETdesogestrel-ethinyl estradiol/ethinyl estradiol
BRAND
KELNOR 1-35 28 TABLETethynodiol diacetate-ethinyl estradiol
BRAND
KIMIDESS 28 DAY TABLETdesogestrel-ethinyl estradiol/ethinyl estradiol
BRAND
KURVELO TABLETlevonorgestrel-ethinyl estradiol
BRAND
LARIN (21 1-20, 1.5 MG-30 MCG) BRAND
PAGE 86 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
norethindrone acetate-ethinyl estradiol
LARIN 24 FE 1 MG-20 MCG TABLETnorethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
LARIN FE (1.5-30, 1-20)norethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
LEENA 28 TABLETnorethindrone-ethinyl estradiol
BRAND
LESSINA-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
LEVONEST-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
LEVONORGESTREL (1.5 MG, 0.75 MG) generic
LEVONORGESTREL-ETHINYL ESTRADIOL (90-20MCGTABLET, 0.15-0.03 TBDSPK 3MO, 0.1-0.02 TABLET, 6-5-10 TABLET, 0.15-0.03 TABLET)
generic
LEVONORGESTREL/ETHINYL ESTRADIOL ANDETHINYL ESTRADIOL (150-30(84), 100-20(84))
generic
LEVORA-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
LOMEDIA 24 FE 1 MG-20 MCG TABnorethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
LOPREEZA 1 MG-0.5 MG TABLETestradiol/norethindrone acetate
BRAND
LORYNA 3 MG-0.02 MG TABLETethinyl estradiol/drospirenone
BRAND
LOW-OGESTREL-28 TABLETnorgestrel-ethinyl estradiol
BRAND
LUTERA-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
MARLISSA-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
MENEST (1.25 MG, 0.625 MG, 2.5 MG, 0.3 MG)estrogens,esterified
BRAND
MICROGESTIN (21 1.5-30 TAB, 21 1-20 TABLET)norethindrone acetate-ethinyl estradiol
BRAND
MICROGESTIN 24 FE 1 MG-20 MCGnorethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
MICROGESTIN FE 1-20 TABLETnorethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
MIMVEY 1-0.5 MG TABLET BRAND
PAGE 87 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
estradiol/norethindrone acetate
MIMVEY LO 0.5-0.1 MG TABLETestradiol/norethindrone acetate
BRAND
MONO-LINYAH 28 TABLETnorgestimate-ethinyl estradiol
BRAND
MONONESSA 28 TABLETnorgestimate-ethinyl estradiol
BRAND
MY WAY 1.5 MG TABLETlevonorgestrel
BRAND
MYZILRA-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
NECON (1-35-28, 7-7-7-28, 10-11-28, 1-50-28, 0.5-35-28)norethindrone-ethinyl estradiol
BRAND
NEXT CHOICE ONE DOSE 1.5 MG TBlevonorgestrel
BRAND
NIKKI 3 MG-0.02 MG TABLETethinyl estradiol/drospirenone
BRAND
noreth-ethinyl estradiol/iron 0.8-25(24) tab chew generic
NORETHINDRONE ACETATE-ETHINYL ESTRADIOL(0.5MG-2.5, 1MG-20MCG, 1MG-5MCG)
generic
NORETHINDRONE ACETATE-ETHINYLESTRADIOL/FERROUS FUMARATE (1MG-20(24), 1MG-20(21))
generic
NORGESTIMATE-ETHINYL ESTRADIOL (0.25-0.035,7DAYSX3 28, 7DAYSX3 LO)
generic
NORTREL (7-7-7-28, 1-35, 0.5-35)norethindrone-ethinyl estradiol
BRAND
OCELLA 3 MG-0.03 MG TABLETethinyl estradiol/drospirenone
BRAND
OGEN 2.5 TABLETestropipate
BRAND
OGESTREL TABLETnorgestrel-ethinyl estradiol
BRAND
ORSYTHIA-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
PHILITH 0.4-0.035 MG TABLETnorethindrone-ethinyl estradiol
BRAND
PIMTREA 28 DAY TABLETdesogestrel-ethinyl estradiol/ethinyl estradiol
BRAND
PIRMELLA (1-35-28, 7-7-7-28) BRAND
PAGE 88 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
norethindrone-ethinyl estradiol
PORTIA-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
PREMPHASE 0.625-5 MG TABLETestrogens, conjugated/medroxyprogesterone acetate
BRAND
PREMPRO (0.625-5 MG, 0.625-2.5 MG, 0.45-1.5 MG, 0.3MG-1.5 MG)estrogens, conjugated/medroxyprogesterone acetate
BRAND
PREVIFEM TABLETnorgestimate-ethinyl estradiol
BRAND
QUASENSE 0.15-0.03 MG TABLETlevonorgestrel-ethinyl estradiol
BRAND
RECLIPSEN 28 DAY TABLETdesogestrel-ethinyl estradiol
BRAND
SETLAKIN 0.15 MG-0.03 MG TABlevonorgestrel-ethinyl estradiol
BRAND
SPRINTEC 28 DAY TABLETnorgestimate-ethinyl estradiol
BRAND
SRONYX 0.10-0.02 MG TABLETlevonorgestrel-ethinyl estradiol
BRAND
SYEDA 28 TABLETethinyl estradiol/drospirenone
BRAND
TARINA FE 1-20 TABLETnorethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
TRI-ESTARYLLA TABLETnorgestimate-ethinyl estradiol
BRAND
TRI-LEGEST FE-28 DAY TABLETnorethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
TRI-LINYAH TABLETnorgestimate-ethinyl estradiol
BRAND
TRI-LO-ESTARYLLA TABLETnorgestimate-ethinyl estradiol
BRAND
TRI-LO-MARZIA TABLETnorgestimate-ethinyl estradiol
BRAND
TRI-LO-SPRINTEC TABLETnorgestimate-ethinyl estradiol
BRAND
TRI-PREVIFEM TABLETnorgestimate-ethinyl estradiol
BRAND
TRI-SPRINTEC TABLETnorgestimate-ethinyl estradiol
BRAND
PAGE 89 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
TRINESSA TABLETnorgestimate-ethinyl estradiol
BRAND
TRIVORA-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
VAGIFEM 10 MCG VAGINAL TABestradiol
BRAND
VELIVET 28 DAY TABLETdesogestrel-ethinyl estradiol
BRAND
VESTURA 3 MG-0.02 MG TABLETethinyl estradiol/drospirenone
BRAND
VIENVA-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
VIORELE 28 DAY TABLETdesogestrel-ethinyl estradiol/ethinyl estradiol
BRAND
VYFEMLA 28 TABLETnorethindrone-ethinyl estradiol
BRAND
WERA 0.5/0.035 MG 28 TABLETnorethindrone-ethinyl estradiol
BRAND
WYMZYA FE CHEWABLE TABLETnorethindrone-ethinyl estradiol/ferrous fumarate
BRAND
ZARAH TABLETethinyl estradiol/drospirenone
BRAND
ZENCHENT 0.4 MG-35 MCG TABLETnorethindrone-ethinyl estradiol
BRAND
ZENCHENT FE TABLET CHEWABLEnorethindrone-ethinyl estradiol/ferrous fumarate
BRAND
ZEOSA CHEWABLE TABLETnorethindrone-ethinyl estradiol/ferrous fumarate
BRAND
ZOVIA 1-35E TABLETethynodiol diacetate-ethinyl estradiol
BRAND
ZOVIA 1-50E TABLETethynodiol diacetate-ethinyl estradiol
BRAND
PROGESTINS
CAMILA TABLETnorethindrone
BRAND
DEBLITANE 0.35 MG TABLETnorethindrone
BRAND
DEPO-PROVERA 400 MG/ML VIALmedroxyprogesterone acetate
BRAND
ENDOMETRIN 100 MG SUPPOSITORY BRAND S Specialty Drug
PAGE 90 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
progesterone,micronized
ERRIN 0.35 MG TABLETnorethindrone
BRAND
HEATHER TABLETnorethindrone
BRAND
IMPLANON 68 MG IMPLANTetonogestrel
BRAND
JENCYCLA 0.35 MG TABLETnorethindrone
BRAND
JOLIVETTE TABLETnorethindrone
BRAND
LYZA 0.35 MG TABLETnorethindrone
BRAND
MAKENA 1,250 MG/5 ML VIALhydroxyprogesterone caproate
BRANDPA
GL Male
MEDROXYPROGESTERONE ACETATE (2.5 MGTABLET, 150 MG/ML VIAL, 5 MG TABLET, 150 MG/MLSYRINGE, 10 MG TABLET)
generic
MEGESTROL ACETATE (20 MG TABLET, 625MG/5MLORAL SUSP, 400MG/10ML ORAL SUSP, 40 MGTABLET)
generic
NORA-BE TABLETnorethindrone
BRAND
norethindrone 0.35 mg tablet generic
norethindrone acetate 5 mg tablet generic
NORLYROC 0.35 MG TABLETnorethindrone
BRAND
progesterone 50 mg/ml vial generic
PROGESTERONE,MICRONIZED (100 MG, 200 MG) generic
SHAROBEL 0.35 MG TABLETnorethindrone
BRAND
SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS
raloxifene hcl 60 mg tablet generic
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)
ARMOUR THYROID (60 MG, 300 MG, 120 MG, 30 MG,90 MG, 240 MG, 180 MG, 15 MG)thyroid,pork
BRAND
LEVOTHYROXINE SODIUM (75 MCG, 300 MCG, 25 generic
PAGE 91 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
MCG, 112 MCG, 137 MCG, 125 MCG, 100 MCG, 200MCG, 50 MCG, 175MCG, 88 MCG, 150 MCG)
LEVOXYL (112 MCG, 125 MCG, 88 MCG, 50 MCG, 200MCG, 137 MCG, 75 MCG, 100 MCG, 150 MCG, 175 MCG,25 MCG)levothyroxine sodium
BRAND
LIOTHYRONINE SODIUM (25 MCG TABLET, 5 MCGTABLET, 50 MCG TABLET, 10 MCG/ML VIAL)
generic
NATURE-THROID (146.25 MG, 65 MG, 113.75 MG, 32.5MG, 81.25 MG, 162.5 MG, 130 MG, 16.25 MG, 325 MG,195 MG, 97.5 MG, 48.75 MG, 260 MG)thyroid,pork
BRAND
NP THYROID (90 MG, 30 MG, 60 MG)thyroid,pork
BRAND
THYROLAR-1 STRENGTH TABLETliotrix
BRAND
THYROLAR-1/2 STRENGTH TABliotrix
BRAND
THYROLAR-1/4 STRENGTH TABliotrix
BRAND
THYROLAR-2 STRENGTH TABLETliotrix
BRAND
THYROLAR-3 STRENGTH TABLETliotrix
BRAND
UNITHROID (137 MCG, 88 MCG)levothyroxine sodium
BRAND
WESTHROID (130 MG, 97.5 MG, 16.25 MG, 65 MG, 48.75MG, 32.5 MG, 195 MG)thyroid,pork
BRAND
HORMONAL AGENTS, SUPPRESSANT (PARATHYROID)
SENSIPAR (30 MG, 60 MG)cinacalcet hcl
BRAND
QL
PA
S Specialty Drug
SENSIPAR 90 MG TABLETcinacalcet hcl
BRAND
QL
PA
S Specialty Drug
HORMONAL AGENTS, SUPPRESSANT (PITUITARY)
cabergoline 0.5 mg tablet generic
PAGE 92 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
EGRIFTA 1 MG VIALtesamorelin acetate
BRAND PA
EGRIFTA 2 MG VIALtesamorelin acetate
BRAND S Specialty Drug
LEUPROLIDE ACETATE (1 KIT, 1 VIAL) generic
LUPRON DEPOT (DEPOT 7.5 MG, DEPOT 22.5 MG3MO, DEPOT 11.25 MG 3MO, DEPOT-4 MONTH, DEPOT3.75 MG, DEPOT 45 MG 6MO)leuprolide acetate
BRANDPA
S Specialty Drug
LUPRON DEPOT-PED (11.25 MG 3MO, 30 MG 3MO KIT,7.5 MG KIT, 11.25 MG KIT, 15 MG KIT)leuprolide acetate
BRANDPA
S Specialty Drug
OCTREOTIDE ACETATE (500 MCG/ML, 50 MCG/ML, 100MCG/ML)
genericPA
S Specialty Drug
SIGNIFOR (0.6 MG/ML, 0.9 MG/ML, 0.3 MG/ML)pasireotide diaspartate
BRAND S Specialty Drug
VANTAS 50 MG KIThistrelin acetate
BRAND PA
HORMONAL AGENTS, SUPPRESSANT (THYROID)
ANTITHYROID AGENTS
METHIMAZOLE (5 MG, 10 MG) generic
propylthiouracil 50 mg tablet generic
IMMUNOLOGICAL AGENTS
ANGIOEDEMA (HAE) AGENTS
FIRAZYR 30 MG/3 ML SYRINGEicatibant acetate
BRAND
IMMUNE SUPPRESSANTS
AZASAN (75 MG, 100 MG)azathioprine
BRAND
azathioprine 50 mg tablet generic
CELLCEPT (200 MG/ML ORAL SUSP, 500 MG VIAL)mycophenolate mofetil hcl
BRAND
CYCLOSPORINE (100 MG CAPSULE, 250 MG/5ML VIAL,250 MG/5ML AMPUL, 25 MG CAPSULE)
generic
CYCLOSPORINE, MODIFIED (50 MG CAPSULE, 100MG/ML SOLUTION, 100 MG CAPSULE, 25 MGCAPSULE)
generic
PAGE 93 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
ENBREL (50 MG/ML SYRINGE, 25 MG KIT, 50 MG/MLSURECLICK SYR, 25 MG/0.5 ML SYRINGE)etanercept
BRANDPA
S Specialty Drug
GENGRAF (25 MG CAPSULE, 100 MG/ML SOLUTION,100 MG CAPSULE)cyclosporine, modified
BRAND
HECORIA (1 MG, 5 MG, 0.5 MG)tacrolimus
BRAND
HUMIRA (10 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML)adalimumab
BRANDPA
S Specialty Drug
HUMIRA 40 MG/0.8 ML PENadalimumab
BRANDPA
S Specialty Drug
HUMIRA PEDIATRIC CROHN'S STARTadalimumab
BRANDPA
S Specialty Drug
HUMIRA PEN CROHN'S-UC-HS STARTadalimumab
BRANDPA
S Specialty Drug
HUMIRA PEN PSORIASIS START PKadalimumab
BRANDPA
S Specialty Drug
METHOTREXATE SODIUM (25 MG/ML VIAL, 2.5 MGTABLET)
generic
methotrexate sodium/pf 1 g vial generic
methotrexate sodium/pf 25 mg/ml vial generic S Specialty Drug
MYCOPHENOLATE MOFETIL (500 MG TABLET, 250 MGCAPSULE)
generic
MYCOPHENOLATE SODIUM (180 MG, 360 MG) generic
MYFORTIC (360 MG, 180 MG)mycophenolate sodium
BRAND
NULOJIX 250 MG VIALbelatacept
BRAND
PROGRAF 5 MG/ML AMPULEtacrolimus
BRAND
RAPAMUNE (1 MG TABLET, 1 MG/ML ORAL SOLN, 2MG TABLET)sirolimus
BRAND
REMICADE 100 MG VIALinfliximab
BRAND PA
SIROLIMUS (1 MG, 0.5 MG) generic
PAGE 94 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
TACROLIMUS (1 MG, 5 MG, 0.5 MG) generic
TREXALL (15 MG, 10 MG, 7.5 MG, 5 MG)methotrexate sodium
BRAND
ZORTRESS (0.75 MG, 0.5 MG, 0.25 MG)everolimus
BRAND S Specialty Drug
IMMUNIZING AGENTS, PASSIVE
BIVIGAM LIQUID 10% VIALimmune globulin,gamm(igg)/glycine/iga greater than 50mcg/ml
BRAND PA
FLEBOGAMMA DIF (10%, 5%)immune globulin,gamma (igg)/sorbitol/iga 0 to 50 mcg/ml
BRAND PA
GAMMAGARD LIQUID 10% VIALimmune globulin,gamm(igg)/glycine/iga greater than 50mcg/ml
BRAND PA
GAMMAPLEX 5% VIALimmune globulin,gamm(igg)/sorbitol/glycin/iga 0 to 50mcg/ml
BRAND PA
GAMUNEX 10% VIALimmune globulin,gamma caprylate (igg)
BRAND PA
GAMUNEX-C (2.5 GRAM/25 ML, 1 GRAM/10 ML, 10GRAM/100 ML, 20 GRAM/200 ML, 5 GRAM/50 ML)immune globulin,gamm(igg)/glycine/iga greater than 50mcg/ml
BRAND PA
HIZENTRA (10 GRAM/50 ML, 2 GRAM/10 ML, 1 GRAM/5ML, 4 GRAM/20 ML)immune globulin,gamma (igg)/proline/iga 0 to 50 mcg/ml
BRAND
HYPERRHO S-D 250 UNITS SYRINGErho(d) immune globulin
BRAND
PRIVIGEN 10% VIALimmune globulin,gamma (igg)/proline/iga 0 to 50 mcg/ml
BRAND PA
VARIZIG 125 UNIT VIALvaricella-zoster immune globulin (human)
BRAND
IMMUNOMODULATORS
ACTEMRA 162 MG/0.9 ML SYRINGEtocilizumab
BRAND PA
ACTIMMUNE 100 MCG/0.5 ML VIALinterferon gamma-1b,recomb.
BRAND S Specialty Drug
ARCALYST 220 MG INJECTIONrilonacept
BRAND S Specialty Drug
BENLYSTA (120 MG, 400 MG)belimumab
BRAND
PAGE 95 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
ILARIS 180 MG VIALcanakinumab/pf
BRAND
LEFLUNOMIDE (20 MG, 10 MG) generic
RIDAURA 3 MG CAPSULEauranofin
BRAND
SYNAGIS (50 MG/0.5 ML, 100 MG/1 ML)palivizumab
BRAND PA
VACCINES
ADACEL TDAP VIALdiphtheria,pertussis(acell),tetanus vaccine/pf
BRAND
EZ FLU 2015-16 (FLUVIRIN) KITinfluenza virus vaccine trivalnt 2015-2016 (4 yr & older)/pf
BRAND
PNEUMOVAX 23 SYRINGEpneumococcal 23-valent polysaccharide vaccine
BRAND
PNEUMOVAX 23 VIALpneumococcal 23-valent polysaccharide vaccine
BRAND AL 1 to 65 yrs old
ZOSTAVAX VIALzoster vaccine live/pf
BRAND
INFLAMMATORY BOWEL DISEASE AGENTS
AMINOSALICYLATES
APRISO ER 0.375 GRAM CAPSULEmesalamine
BRAND
balsalazide disodium 750 mg capsule generic
CANASA 1,000 MG SUPPOSITORYmesalamine
BRAND
mesalamine 4 g/60 ml enema generic
mesalamine w/cleansing wipes 4 g/60 ml enema kit generic
PENTASA (500 MG, 250 MG)mesalamine
BRAND
GLUCOCORTICOIDS
budesonide 3 mg capdr - er generic
COLOCORT 100 MG ENEMAhydrocortisone
BRAND
CORTIFOAM 10% AEROSOLhydrocortisone acetate
BRAND
hydrocortisone 100mg/60ml enema generic
PROCTO-PAK 1% CREAM BRAND
PAGE 96 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
hydrocortisone
PROCTOSOL-HC 2.5% CREAMhydrocortisone
BRAND
PROCTOZONE-HC 2.5% CREAMhydrocortisone
BRAND
UCERIS 9 MG ER TABLETbudesonide
BRAND
SULFONAMIDES
SULFASALAZINE (500 MG, 500 MG DR) generic
SULFAZINE 500 MG TABLETsulfasalazine
BRAND
SULFAZINE EC 500 MG TABsulfasalazine
BRAND
METABOLIC BONE DISEASE AGENTS
ALENDRONATE SODIUM (10 MG TABLET, 70 MG/75MLSOLUTION, 40 MG TABLET, 35 MG TABLET, 70 MGTABLET, 5 MG TABLET)
generic
calcitonin,salmon,synthetic 200/spray spray/pump generic
CALCITRIOL (1 MCG/ML SOLUTION, 0.5 MCGCAPSULE, 0.25 MCG CAPSULE, 1 MCG/ML AMPUL)
generic
DOXERCALCIFEROL (1 MCG, 2.5 MCG, 0.5 MCG) generic S Specialty Drug
ETIDRONATE DISODIUM (200 MG, 400 MG) generic
FORTEO 600 MCG/2.4 ML PEN INJteriparatide
BRANDPA
S Specialty Drug
FORTICAL 200 UNITS NASAL SPRAYcalcitonin,salmon,synthetic
BRAND
HECTOROL (2 MCG/ML, 4 MCG/2 ML)doxercalciferol
BRAND S Specialty Drug
ibandronate sodium 150 mg tablet generic
PARICALCITOL (2 MCG/ML VIAL, 2 MCG CAPSULE, 5MCG/ML VIAL, 4MCG CAPSULE, 1 MCG CAPSULE)
generic
RISEDRONATE SODIUM (5 MG, 30 MG, 35 MG DR, 150MG, 35 MG)
generic
MISCELLANEOUS THERAPEUTIC AGENTS
acetylcysteine 200 mg/ml vial generic PA
ALBUTEIN 25% VIAL BRAND
PAGE 97 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
albumin human
APLIGRAF DISKcult skin subst,human-bovine
BRAND
AVITENE SHEET 70MMX70MMmicrofibrillar collagen
BRAND
coal tar 20 % solution generic
DEFEROXAMINE MESYLATE (2 G, 500 MG) generic
dexmedetomidine hcl 200mcg/2ml vial generic
ENDO-AVITENE 5MM SHEETmicrofibrillar collagen
BRAND
EUFLEXXA 20 MG/2 ML SYRINGEhyaluronate sodium
BRAND PA
flumazenil 0.1 mg/ml vial generic
fomepizole 1 g/ml vial generic
FORMADON 10% SOLUTIONformaldehyde
BRAND
formaldehyde 10 % sol w/appl generic
glutaraldehyde 25 % solution generic
glycine/sod/water/sod hydrox vial generic S Specialty Drug
IC GREEN 25 MG VIALindocyanine green
BRAND
isomethept/dichlphn/acetaminop 65-100-325 capsule generic
isomethepten/caf/acetaminophen 65-20-325 tablet generic
isosulfan blue 1 % vial generic
LMD 10% WITH 0.9% SOD CHL SOLNdextran 40 in 0.9 % sodium chloride
BRAND
LMD 10% WITH 5% DEXT SOLNdextran 40/dextrose 5 % in water
BRAND
LUGOL'S SOLUTIONpotassium iodide/iodine
BRAND
MD-GASTROVIEW 66%-10% SOLNdiatrizoate meglumine/diatrizoate sodium
BRAND
METHYLENE BLUE (1 VIAL, 1 AMPUL) generic
METHYLERGONOVINE MALEATE (0.2 MG TABLET,.2MG/ML(1) AMPUL)
generic
MIGRAGESIC IDA CAPSULEisometheptene mucate/dichloralphenazone/acetaminophen
BRAND
PAGE 98 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
NODOLOR CAPSULEisometheptene mucate/dichloralphenazone/acetaminophen
BRAND
oxytocin 10 unit/ml vial generic
PANHEMATIN 313 MG VIALhemin
BRAND
phenol liquid generic
physostigmine salicylate 1 mg/ml ampul generic
potassium iodide/iodine 5 % solution generic
PROTOPAM CHLORIDE 1 GM VIALpralidoxime chloride
BRAND
SITZMARKS CAPSULEradiopaque pvc markers/barium sulfate
BRAND
sodium morrhuate 50 mg/ml vial generic
SODIUM THIOSULFATE (1 G/10 ML, 12.5G/50ML) generic
SOLIRIS 300 MG/30 ML VIALeculizumab
BRAND PA
SOTRADECOL 3% VIALsodium tetradecyl sulfate
BRAND
water for inj.,bacteriostatic vial generic
WATER FOR INJECTION,STERILE (IVSOLN, AMPUL,VIAL)
generic
water for irrigation,sterile irrig soln generic
water/me-paraben/propylparaben vial generic
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS, OTHER
AKORN BALANCED SALT SOLNbalanced salt irrig soln no.2
BRAND
ALTACAINE 0.5% EYE DROPStetracaine hcl
BRAND
ALTAFLUOR EYE DROPSbenoxinate hcl/fluorescein sodium
BRAND
ATROPINE CARE 1% EYE DROPSatropine sulfate
BRAND
ATROPINE SULFATE (1 DROPS, 1 OINT. (G)) generic
balanced salt irrig soln no.2 irrig soln generic
benoxinate hcl/fluorescein na 0.4%-0.25% drops generic
PAGE 99 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
BIOGLO 1 MG OPHTHALMIC STRIPSfluorescein sodium
BRAND
BSS EYE SOLUTIONbalanced salt irrig soln no.2
BRAND
ciprofloxacin hcl 0.3 % drops generic
CYCLOPENTOLATE HCL (2, 1) generic
CYSTARAN 0.44% EYE DROPScysteamine hcl
BRAND
ERYTHROMYCIN BASE (5 MG/G, 5MG/G) generic
FLUCAINE EYE DROPSproparacaine hcl/fluorescein sodium
BRAND
FLUOR-I-STRIP ATfluorescein sodium
BRAND
FLUORESCITE 10% VIALfluorescein sodium
BRAND
FLUORETS 1 MG OPTH STRIPSfluorescein sodium
BRAND
FLUROX EYE DROPSbenoxinate hcl/fluorescein sodium
BRAND
FUL-GLO 1 MG OPTH STRIPSfluorescein sodium
BRAND
GARAMYCIN (0.3%, 3 MG/ML)gentamicin sulfate
BRAND
gatifloxacin 0.5 % drops generic
GENTAK 0.3 % EYE OINTMENTgentamicin sulfate
BRAND
GENTAMICIN SULFATE (0.3 OINT. (G), 0.3 DROPS) generic
HOMATROPAIRE 5% EYE DROPShomatropine hbr
BRAND
homatropine hbr 5 % drops generic
levofloxacin 0.5 % drops generic
MOXEZA 0.5% EYE DROPSmoxifloxacin hcl
BRAND
naphazoline hcl 0.1 % drops generic
NEO-POLYCIN EYE OINTMENTneomycin sulfate/bacitracin/polymyxin b
BRAND
NEO-POLYCIN HC EYE OINTMENTneomycin sulfate/bacitracin zinc/polymyxinb/hydrocortisone
BRAND
PAGE 100 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
neomycin su/baci zn/poly/hc 3.5-10k-1 oint. (g) generic
neomycin su/bacitra/polymyxin 3.5mg-400 oint. (g) generic
neomycin/polymyxin b sulf/hc 3.5-10k-10 drops susp generic
NEOMYCIN/POLYMYXIN BSULFATE/DEXAMETHASONE (0.1 % DROPS SUSP, 3.5-10K-.1 OINT. (G))
generic
neomycin/polymyxn b/gramicidin 1.75mg-10k drops generic
OCUCOAT VISCOADHERENT SYRINGEhypromellose
BRAND
ofloxacin 0.3 % drops generic
PHENYLEPHRINE HCL (10, 2.5) generic
POLYCIN EYE OINTMENTbacitracin/polymyxin b sulfate
BRAND
polymyxin b sulf/trimethoprim 10000-1/ml drops generic
proparacaine hcl 0.5 % drops generic
proparacaine/fluorescein sod 0.5%-0.25% drops generic
RESTASIS 0.05% EYE EMULSIONcyclosporine
BRAND
SULFACETAMIDE SODIUM (10 DROPS, 10 OINT. (G)) generic
sulfacetamide/prednisolone sp 10 %-0.23% drops generic
TETCAINE 0.5% EYE DROPStetracaine hcl
BRAND
tetracaine hcl 0.5 % drops generic
tetracaine hcl/pf 0.5 % drops generic
tobramycin 0.3 % drops generic
tobramycin/dexamethasone 0.3 %-0.1% drops susp generic
TROPICAMIDE (0.5, 1) generic
OPHTHALMIC ANTI-ALLERGY AGENTS
azelastine hcl 0.05 % drops generic
cromolyn sodium 4 % drops generic
epinastine hcl 0.05 % drops generic
olopatadine hcl 0.1 % drops generic
OPHTHALMIC ANTI-INFLAMMATORIES
bromfenac sodium 0.09% drops generic
dexamethasone sod phosphate 0.1 % drops generic
PAGE 101 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
diclofenac sodium 0.1 % drops generic
fluorometholone 0.1 % drops susp generic
flurbiprofen sodium 0.03 % drops generic
KETOROLAC TROMETHAMINE (0.5, 0.4) generic
PRED MILD 0.12% EYE DROPSprednisolone acetate
BRAND
prednisolone acetate 1 % drops susp generic
prednisolone sod phosphate 1 % drops generic
OPHTHALMIC ANTIGLAUCOMA AGENTS
ALPHAGAN P 0.1% DROPSbrimonidine tartrate
BRAND
apraclonidine hcl 0.5 % drops generic
betaxolol hcl 0.5 % drops generic
BRIMONIDINE TARTRATE (0.2, 0.15) generic
carteolol hcl 1 % drops generic
dorzolamide hcl 2 % drops generic
dorzolamide hcl/timolol maleat 22.3-6.8/1 drops generic
levobunolol hcl 0.5 % drops generic
METHAZOLAMIDE (50 MG, 25 MG) generic
metipranolol 0.3 % drops generic
MIOSTAT VIALcarbachol
BRAND
PHOSPHOLINE IODIDE 0.125%echothiophate iodide
BRAND
PILOCARPINE HCL (4, 2, 1) generic
TIMOLOL MALEATE (0.25 DROPS, 0.5 SOL-GEL, 0.5DROPS, 0.25 SOL-GEL)
generic
OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS
bimatoprost 0.03 % drops generic
latanoprost 0.005 % drops generic
travoprost (benzalkonium) 0.004 % drops generic
OTIC AGENTS
ACETASOL HC EAR DROPSacetic acid/hydrocortisone
BRAND
PAGE 102 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
acetic acid 2 % solution generic
acetic acid/aluminum acetate 2 % drops generic
acetic acid/hydrocortisone 2 %-1 % drops generic
AERO OTIC HC EAR DROPShydrocortisone/pramoxine hcl/chloroxylenol
BRAND
ANTIPYRINE/BENZOCAINE (5.4, 5.5) generic
AURODEX OTIC SOLUTIONantipyrine/benzocaine
BRAND
AUROGUARD OTIC SOLUTIONantipyrine/benzocaine
BRAND
CIPRODEX OTIC SUSPENSIONciprofloxacin hcl/dexamethasone
BRAND
CORTANE-B OTIC DROPShydrocortisone/pramoxine hcl/chloroxylenol/water
BRAND
EXOTIC-HC EAR DROPhydrocortisone/pramoxine hcl/chloroxylenol
BRAND
fluocinolone acetonide oil 0.01 % drops generic
NEOMYCIN SULFATE/POLYMYXIN BSULFATE/HYDROCORTISONE (SOLUTION, DROPSSUSP)
generic
ofloxacin 0.3 % drops generic
OTICIN HC DROPShydrocortisone/pramoxine hcl/chloroxylenol
BRAND
OTO-END 10 EAR DROPShydrocortisone/pramoxine hcl/chloroxylenol
BRAND
OTOMAX-HC EAR DROPShydrocortisone/pramoxine hcl/chloroxylenol
BRAND
OTOZIN EAR DROPSantipyrine/benzocaine/glycerin/zinc acetate
BRAND
PRAMOXINE-HC OTIC DROPShydrocortisone/pramoxine hcl/chloroxylenol
BRAND
RESPIRATORY TRACT/PULMONARY AGENTS
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS
ARNUITY ELLIPTA (200 MCG, 100 MCG)fluticasone furoate
BRAND QL
BUDESONIDE (1 MG/2 ML AMPUL-NEB, 32MCGSPRAY/PUMP)
generic
budesonide 0.25mg/2ml ampul-neb generic QL
PAGE 103 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
C 2 vials (4ml)/day
budesonide 0.5 mg/2ml ampul-neb generic C 2 vials (4ml)/day
flunisolide 25 mcg spray generic
fluticasone propionate 50 mcg spray susp generic
PULMICORT FLEXHALER (90 MCG, 180 MCG)budesonide
BRAND
QVAR (80 MCG, 40 MCG)beclomethasone dipropionate
BRAND
triamcinolone acetonide 55 mcg spray generic
ANTIHISTAMINES
ARBINOXA (4 MG TABLET, 4 MG/5 ML LIQUID)carbinoxamine maleate
BRAND
AZELASTINE HCL (205.5MCG, 137 MCG) generic
CARBINOXAMINE MALEATE (4 MG TABLET, 4 MG/5 MLLIQUID)
generic
CLEMASTINE FUMARATE (2.68 MG TABLET,0.67MG/5ML SYRUP)
generic
CYPROHEPTADINE HCL (4 MG TABLET, 2 MG/5 MLSYRUP)
generic
DESLORATADINE (2.5 MG, 5 MG) generic
ST
C
must trycetirizine,cetirizine/pseudoephedrine,loratadine,loratadine/pseudoephedrine
desloratadine 5 mg tablet generic
PA
ST
C
must trycetirizine,cetirizine/pseudoephedrine,loratadine,loratadine/pseudoephedrine
diphenhydramine hcl 50 mg/ml vial generic
HYDROXYZINE HCL (10 MG TABLET, 50 MG/ML VIAL,25 MG/ML VIAL, 50 MG/25ML SOLUTION, 10 MG/5 MLSOLUTION, 50 MG TABLET, 25 MG TABLET)
generic
HYDROXYZINE PAMOATE (100 MG, 50 MG, 25 MG) generic
PAGE 104 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
levocetirizine dihydrochloride 2.5 mg/5ml solution generic
PA
ST
C
must try cetirizine,cetirizine/pseudoephedrine, loratadine,loratadine/pseudoephedrine
levocetirizine dihydrochloride 5 mg tablet generic
PA
ST
C
must try cetirizine,cetirizine/pseudoephedrine, loratadine,loratadine/pseudoephedrine
olopatadine hcl 0.6 % spray/pump generic
PALGIC (4 MG/5 ML LIQUID, 4 MG TABLET)carbinoxamine maleate
BRAND
PHENADOZ (12.5 MG, 25 MG)promethazine hcl
BRAND
PHENERGAN (50 MG, 12.5 MG, 25 MG)promethazine hcl
BRAND
PROMETHAZINE HCL (25 MG/ML VIAL, 25 MG TABLET,50 MG/ML AMPUL, 50 MG SUPP.RECT, 12.5 MGSUPP.RECT, 50 MG TABLET, 12.5 MG TABLET, 25MG/ML AMPUL, 25 MG SUPP.RECT, 6.25MG/5MLSYRUP, 50 MG/ML VIAL)
generic
PROMETHEGAN (50 MG SUPPOSITORY, 25 MG SUPP,12.5 MG SUPPOS)promethazine hcl
BRAND
ANTILEUKOTRIENES
MONTELUKAST SODIUM (4 MG GRAN PACK, 10 MGTABLET, 4 MG TAB CHEW, 5 MG TAB CHEW)
generic
zafirlukast 10 mg tablet generic PA
zafirlukast 20 mg tablet generic
BRONCHODILATORS, ANTICHOLINERGIC
ATROVENT HFA INHALERipratropium bromide
BRAND
IPRATROPIUM BROMIDE (42 MCG SPRAY, 21 MCGSPRAY, 0.2 MG/ML SOLUTION)
generic
SPIRIVA 18 MCG CP-HANDIHALERtiotropium bromide
BRAND
SPIRIVA RESPIMAT 1.25 MCG INH BRAND
PAGE 105 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
tiotropium bromide
TUDORZA PRESSAIR 400 MCG INHaclidinium bromide
BRAND
BRONCHODILATORS, SYMPATHOMIMETIC
ADRENALIN 1 MG/ML VIALepinephrine
BRAND C 2 kits/fill
ADRENALIN CL 1 MG/ML VIALepinephrine
BRAND C 2 kits/fill
ALBUTEROL SULFATE (2 MG/5 ML SYRUP,1.25MG/3ML VIAL-NEB, 8 MG TAB ER 12H, 2.5 MG/3MLVIAL-NEB, 2.5 MG/0.5 VIAL-NEB, 4 MG TAB ER 12H, 2MG TABLET, 0.63MG/3ML VIAL-NEB, 5 MG/MLSOLUTION, 4 MG TABLET)
generic
EPINEPHRINE (1 MG/ML VIAL, 0.1 MG/ML SYRINGE,0.3MG/0.3 AUTO INJCT, 1 MG/ML(1) AMPUL, 0.15/0.15AUTO INJCT)
generic C 2 kits/fill
epinephrine hcl/pf 1 mg/ml(1) ampul generic C 2 kits/fill
epinephrine/pf 1 mg/ml(1) ampul generic C 2 kits/fill
EPIPEN 2-PAK 0.3 MG AUTO-INJCTepinephrine
BRAND C 2 kits/fill
EPIPEN JR 2-PAK 0.15 MG INJCTRepinephrine
BRAND C 2 kits/fill
LEVALBUTEROL HCL (0.63MG/3ML, 1.25MG/0.5,1.25MG/3ML, 0.31MG/3ML)
generic C 24 vials/month
METAPROTERENOL SULFATE (10 MG TABLET, 20 MGTABLET, 10 MG/5 ML SYRUP)
generic
PERFOROMIST 20 MCG/2 ML SOLNformoterol fumarate
BRAND
STRIVERDI RESPIMAT INHAL SPRAYolodaterol hcl
BRAND QL
TERBUTALINE SULFATE (5 MG TABLET, 2.5 MGTABLET, 1 MG/ML VIAL)
generic
VENTOLIN HFA 90 MCG INHALERalbuterol sulfate
BRAND QL
CYSTIC FIBROSIS AGENTS
PAGE 106 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
CAYSTON 75 MG INHAL SOLUTIONaztreonam lysine
BRAND
QL
PA
C 3 vials/day; max 84vials/56 days
S Specialty Drug
KALYDECO (75 MG, 50 MG)ivacaftor
BRAND
QL
PA
C 2 packets/day
S Specialty Drug
KALYDECO 150 MG TABLETivacaftor
BRAND
QL
PA
S Specialty Drug
TOBI 300 MG/5 ML SOLUTIONtobramycin in 0.225 % sodium chloride
BRAND
QL
PA
C 2 vials/day
S Specialty Drug
TOBI PODHALER 28 MG INHALE CAPtobramycin
BRAND
QL
PA
C 8 capsules/day
S Specialty Drug
tobramycin in 0.225% nacl 300 mg/5ml ampul-neb generic
QL
PA
C 2 vials/day
S Specialty Drug
tobramycin/nebulizer 300 mg/5ml ampul-neb generic
QL
PA
S Specialty Drug
PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE
AMINOPHYLLINE (500MG/20ML VIAL, 250MG/10MLVIAL, 250MG/10ML AMPUL)
generic
CAFFEINE CITRATED (60 ML VIAL, 60 ML SOLUTION) generic
DIFIL-G 400 TABLETguaifenesin/dyphylline
BRAND
THEOCHRON (ER 300 MG, ER 200 MG, ER 100 MG)theophylline anhydrous
BRAND
PAGE 107 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
THEOPHYLLINE ANHYDROUS (80 MG/15ML ELIXIR,300 MG TAB ER 12H, 600 MG TABLET ER, 400 MGTABLET ER, 100 MG TAB ER 12H, 450 MG TAB ER 12H,80 MG/15ML SOLUTION, 200 MG TAB ER 12H)
generic
THEOPHYLLINE/DEXTROSE 5 % IN WATER(800MG/.25L, 400MG/0.5L, 200MG/0.1L, 200MG/50ML,400MG/.25L)
generic
PULMONARY ANTIHYPERTENSIVES
ADCIRCA 20 MG TABLETtadalafil
BRANDPA
S Specialty Drug
ADEMPAS (0.5 MG, 1.5 MG, 1 MG, 2 MG, 2.5 MG)riociguat
BRANDPA
S Specialty Drug
EPOPROSTENOL SODIUM (GLYCINE) (1.5 MG, 0.5 MG) generic
LETAIRIS (5 MG, 10 MG)ambrisentan
BRANDPA
S Specialty Drug
OPSUMIT 10 MG TABLETmacitentan
BRANDPA
S Specialty Drug
REMODULIN (10 MG/ML, 5 MG/ML, 2.5 MG/ML, 1MG/ML)treprostinil sodium
BRANDPA
S Specialty Drug
REVATIO 10 MG/12.5 ML VIALsildenafil citrate
BRANDPA
S Specialty Drug
sildenafil citrate 10 mg/12.5 vial genericPA
S Specialty Drug
sildenafil citrate 20 mg tablet generic
QL
PA
S Specialty Drug
TRACLEER (125 MG, 62.5 MG)bosentan
BRANDPA
S Specialty Drug
TYVASO (INHALATION REFILL KIT, INSTITUTIONALSTART KIT, INHALATION STARTER KIT, 1.74 MG/2.9 MLSOLUTION)treprostinil/nebulizer/nebulizer accessories
BRANDPA
S Specialty Drug
VELETRI (1.5 MG, 0.5 MG)epoprostenol sodium (arginine)
BRANDPA
S Specialty Drug
PA
PAGE 108 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
VENTAVIS (10 ML, 20 ML)iloprost tromethamine
BRANDS Specialty Drug
RESPIRATORY TRACT AGENTS, OTHER
ACETYLCYSTEINE (100 MG/ML, 200 MG/ML) generic
ARALAST 1,000 MG VIALalpha-1-proteinase inhibitor
BRAND
ARALAST NP (1,000 MG, 500 MG)alpha-1-proteinase inhibitor
BRAND
BENZONATATE (150 MG, 200 MG, 100 MG) generic
BREO ELLIPTA (200-25 MCG, 100-25 MCG)fluticasone furoate/vilanterol trifenatate
BRAND
CENTERGY PEDIATRIC DROPSchlorpheniramine maleate/phenylephrine hcl
BRAND
COMBIVENT RESPIMAT INHAL SPRAYipratropium bromide/albuterol sulfate
BRAND
cromolyn sodium 20 mg/2 ml ampul-neb generic
doxapram hcl 20 mg/ml vial generic
DULERA (200 MCG, 100 MCG)mometasone furoate/formoterol fumarate
BRAND
fexofenadine/pseudoephedrine 180-240mg tab er 24h generic
PA
ST
C
must try cetirizine,cetirizine/pseudoephedrine,loratadine, loratadine/pseudoephedrine
hydrocodone/chlorphen p-stirex 10-8mg/5ml sus er 12h generic
ipratropium/albuterol sulfate 0.5-3mg/3 ampul-neb generic
phenylephrine hcl/prometh hcl 5-6.25mg/5 syrup generic
PROLASTIN (500 MG, 1,000 MG)alpha-1-proteinase inhibitor
BRAND
PROLASTIN C 1,000 MG VIALalpha-1-proteinase inhibitor
BRAND
promethazine hcl/codeine 6.25-10/5 syrup generic
promethazine/dextromethorphan 6.25-15/5 syrup generic
PULMOZYME 1 MG/ML AMPULdornase alfa
BRANDPA
S Specialty Drug
PAGE 109 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
sodium chloride for inhalation 7 % vial-neb generic
STIOLTO RESPIMAT INHAL SPRAYtiotropium bromide/olodaterol hcl
BRAND QL
SYMBICORT (80-4.5 MCG, 160-4.5 MCG)budesonide/formoterol fumarate
BRAND
TUSSIGON 5-1.5 MG TABLEThydrocodone bitartrate/homatropine methylbromide
BRAND
XOLAIR 150 MG VIALomalizumab
BRANDPA
S Specialty Drug
ZEMAIRA 1,000 MG VIALalpha-1-proteinase inhibitor
BRAND
SKELETAL MUSCLE RELAXANTS
ANECTINE 20 MG/ML VIALsuccinylcholine chloride
BRAND
BACLOFEN (20 MG, 10 MG) generic
carisoprodol 250 mg tablet generic
chlorzoxazone 500 mg tablet generic
CYCLOBENZAPRINE HCL (10 MG, 5 MG, 7.5 MG) generic
DANTROLENE SODIUM (100 MG, 50 MG, 25 MG) generic
GABLOFEN (50 MCG/ML SYRINGE, 40,000 MCG/20 MLVIAL, 10,000 MCG/20 ML VIAL)baclofen
BRAND S Specialty Drug
METAXALONE (800 MG, 400 MG) generic
METHOCARBAMOL (750 MG, 500 MG) generic
ORPHENADRINE CITRATE (100 MG TABLET ER, 30MG/ML AMPUL, 30 MG/ML VIAL)
generic
orphenadrine/aspirin/caffeine 50-770-60 tablet generic
REVONTO 20 MG VIALdantrolene sodium
BRAND
TIZANIDINE HCL (6 MG CAPSULE, 4 MG TABLET, 2 MGCAPSULE, 4 MG CAPSULE, 2 MG TABLET)
generic
SLEEP DISORDER AGENTS
GABA RECEPTOR MODULATORS
ESTAZOLAM (1 MG, 2 MG) generic
ESZOPICLONE (2 MG, 1 MG, 3 MG) generic
PAGE 110 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
quazepam 15 mg tablet generic
TEMAZEPAM (7.5 MG, 15 MG, 30 MG, 22.5 MG) generic
TRIAZOLAM (0.25 MG, 0.125 MG) generic
ZALEPLON (10 MG, 5 MG) generic C
must try zolpidem andzaleplon for at least 2weeks of therapy in thepast 90 days
ZOLPIDEM TARTRATE (6.25 MG TAB MPHASE, 10 MGTABLET, 12.5 MG TAB MPHASE, 5 MG TABLET)
generic
SLEEP DISORDERS, OTHER
caffeine/sodium benzoate 250 mg/ml vial generic
FLURAZEPAM HCL (15 MG, 30 MG) generic
HETLIOZ 20 MG CAPSULEtasimelteon
BRAND
QL
PA
S Specialty Drug
MODAFINIL (100 MG, 200 MG) generic PA
ROZEREM 8 MG TABLETramelteon
BRAND
ST
C
must try zolpidem andzoleplon for at least 2weeks of therapy in thepast 90 days
SECONAL SODIUM 100 MG CAPSULEsecobarbital sodium
BRAND
XYREM 500 MG/ML ORAL SOLUTIONsodium oxybate
BRAND S Specialty Drug
THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES
ELECTROLYTE/MINERAL MODIFIERS
CHEMET 100 MG CAPSULEsuccimer
BRAND
EXJADE (500 MG, 250 MG, 125 MG)deferasirox
BRAND PA
FERRIPROX 500 MG TABLETdeferiprone
BRAND S Specialty Drug
KIONEX (15 GM/60 ML SUSPENSION, POWDER)sodium polystyrene sulfonate
BRAND
MARLEXATE POWDERsodium polystyrene sulfonate
BRAND
SAMSCA (30 MG, 15 MG) BRAND S Specialty Drug
PAGE 111 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
tolvaptan
SODIUM POLYSTYRENE SULFONATE (POWDER,30G/120ML ENEMA, 15 G/60 ML ORAL SUSP)
generic
SPS (15 GM/60 ML SUSPENSION, 30 GM/120 MLENEMA)sodium polystyrene sulfonate
BRAND
ELECTROLYTE/MINERAL REPLACEMENT
0.9 % SODIUM CHLORIDE (0.9 0.9 IV SOLN, 0.9 0.9SYRINGE, 0.9 PGGYBK PRT, 0.9 0.9 VIAL, 0.9 PGY VLPRT)
generic
CALCIUM CHLORIDE (100 MG/ML VIAL, 100 MG/MLSYRINGE)
generic
calcium gluconate 100 mg/ml vial generic
calcium/mag/d3/b12/fa/b6/boron 500-300-1 wafer generic
CARBAGLU 200 MG DISPER TABLETcarglumic acid
BRAND S Specialty Drug
CENTRATEX CAPSULEferrous fumarate/folic acid/multivitamins with min no. 15
BRAND
chromic chloride 4mcg/ml vial generic
CORVITA 150 TABLETiron,carbonyl/folic acid/vit c/pyridoxine hcl/vit b12/zinc
BRAND
cupric chloride 0.4 mg/ml vial generic
DELFLEX WITH 1.5% DEXTROSEperitoneal dialysis no.6 with dextrose 1.5 %
BRAND
DELFLEX WITH 2.5% DEXTROSEperitoneal dialysis no.7 with dextrose 2.5 %
BRAND
DELFLEX WITH 4.25% DEXTROSEperitoneal dialysis no.8 with dextrose 4.25 %
BRAND
DEXTROSE 10 % AND 0.2 % SODIUM CHLORIDE (100.2 10 DEHP FR BG, 10 0.2 10 IV SOLN)
generic
dextrose 10 % and 0.45 % nacl 10%-0.45% iv soln generic
dextrose 10 % and 0.9 % nacl 10 %-0.9 % iv soln generic
dextrose 2.5 % and 0.45 % nacl 2.5%-0.45% iv soln generic
dextrose 5 % and 0.3 % nacl 5 %-0.3 % iv soln generic
dextrose 5 % and 0.9 % nacl 5 %-0.9 % iv soln generic
dextrose 5 %-0.2 % nacl 5 %-0.2 % iv soln generic
dextrose 5 %-0.45 % nacl 5 %-0.45 % iv soln generic
PAGE 112 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
dextrose 5% in ringers 5 % iv soln generic
dextrose 5%-lactated ringers 5 % iv soln generic
EFFER-K 25 MEQ TABLET EFFpotassium bicarbonate/citric acid
BRAND
electrolyte-48 solution/d5w 5 % iv soln generic
FE 90 PLUS TABLETiron carbonyl,gluc/folic acid/vit b12/vit c/docusate sodium
BRAND
FE C PLUS TABLETiron,carbonyl/ascorbic acid/cyanocobalamin/folic acid
BRAND
FEROCON CAPSULEferrous fumarate/ascorbic acid/b12-if/folic acid
BRAND
FEROTRINSIC CAPSULEferrous fumarate/ascorbic acid/b12-if/folic acid
BRAND
FERRAPLUS 90 TABLETiron,carbonyl/folic acid/vitamin b12/vitamin c/docusate na
BRAND
FERREX 150 FORTE CAPSULEiron polysaccharide complex/cyanocobalamin/folic acid
BRAND
FERREX 150 FORTE PLUS CAPSULEiron asp gly&ps cmplx/ascorb.cal/vit b12/fa/ca-thr/succ.acid
BRAND
FERREX 28 TABLETiron asp.glycin & fumarate /vit c/fa/mv comb 11/ca-threonate
BRAND
FERROCITE PLUS TABLETiron/folic acid/vitamin b comp and c/minerals
BRAND
FERROGELS FORTE SOFTGELferrous fumarate/ascorbic acid/cyanocobalamin/folic acid
BRAND
FOCALGIN DSS TABLETiron carbonyl,gluc/folic acid/vit b12/vit c/docusate sodium
BRAND
FOLIVANE-F CAPSULEiron fumarate & polysac comp/folic acid/vitamin c/niacin
BRAND
FOLIVANE-PLUS CAPSULEiron fumarate,polysac cplex/folic acid/vit b comp with c #9
BRAND
HEMATINIC-FOLIC ACID TABLETferrous fumarate/folic acid
BRAND
HEMATINIC-VITAMIN-MINERAL TABiron/folic acid/vitamin b comp and c/minerals
BRAND
HEMATOGEN FA SOFTGELferrous fumarate/ascorbic acid/cyanocobalamin/folic acid
BRAND
HEMATOGEN FORTE SOFTGELferrous fumarate/ascorbic acid/cyanocobalamin/folic acid
BRAND
PAGE 113 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
HEMATOGEN SOFTGELferrous fumarate/ascorbic acid/cyanocobalamin/stomachconc
BRAND
HEMETAB IRON SUPPLEMENT TABLETiron polysacchar complx/iron heme polypeptide/folicacid/b12
BRAND
K EFFERVESCENT 25 MEQ TABLETpotassium bicarbonate/citric acid
BRAND
K-PHOS ORIGINAL TABLETpotassium phosphate,monobasic
BRAND
K-SOL (10% (20, 20% (40)potassium chloride
BRAND
K-TAB ER 8 MEQ TABLETpotassium chloride
BRAND
KLOR-CON (25, 20)potassium chloride
BRAND
KLOR-CON 10 MEQ TABLETpotassium chloride
BRAND
KLOR-CON 8 MEQ TABLETpotassium chloride
BRAND
KLOR-CON M10 TABLETpotassium chloride
BRAND
KLOR-CON M15 TABLETpotassium chloride
BRAND
KLOR-CON M20 TABLETpotassium chloride
BRAND
KLOR-CON SPRINKLE (ER 8 CAP, ER 10 CP)potassium chloride
BRAND
KLOR-CON-EF 25 MEQ TAB EFFpotassium bicarbonate/citric acid
BRAND
magnesium chloride 200 mg/ml vial generic
MAGNESIUM SULFATE (4 SYRINGE, 4 VIAL) generic
MAGNESIUM SULFATE IN STERILE WATER (4 G/50 MLPIGGYBACK, 20 G/500ML IV SOLN, 4 G/100 MLPIGGYBACK, 40G/1000ML IV SOLN, 2 G/50 MLPIGGYBACK)
generic
manganese chloride 0.1 mg/ml vial generic
manganese sulfate 0.1 mg/ml vial generic
molybdenum(ammonium molybdate) 25 mcg/ml vial generic
MONOJECT 0.9% SODIUM CL SYRING BRAND
PAGE 114 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
0.9 % sodium chloride
MONOJECT PREFILL 0.9% FLUSH0.9 % sodium chloride
BRAND
MONOJECT PREFILL 0.9% NA SYR0.9 % sodium chloride
BRAND
MULTIGEN CAPLETiron aspgly/ascorb.cal/vit b12/calciumthr/succ.acid/stomach
BRAND
MULTIGEN FOLIC CAPLETiron asp gly/ascorb.cal/vit b12/fa/ca-threonte/succinic acid
BRAND
MULTIGEN PLUS CAPLETiron fumarte &asp gly/ascorb.cal/vit b12/fa/ca-thr/succ.acid
BRAND
MULTITRACE-4 CONC VIALzinc sulfate/cupric sulfate/manganese sulf/chromic chloride
BRAND
MULTITRACE-5 CONC VIALzinc sulfate heptahydrate/cuso4 p-hyd/manganese/chromium/se
BRAND
NATALVIRT FLT TABLETiron carbonyl,gluc/folic acid/vit b12/vit c/docusate sodium
BRAND
NUTRILYTE II VIALsodium/potassium/magnesium/calcium/chloride/acetate
BRAND
NUTRILYTE VIALsodium/potassium/magnes/calcium/chloride/acetate/gluconate
BRAND
POLYSACCHARIDE IRON FORTEiron polysaccharide complex/cyanocobalamin/folic acid
BRAND
pot chloride/pot bicarb/cit ac 25 meq tablet eff generic
POTASSIUM ACETATE (2, 4) generic
potassium bicarbonate/cit ac 25 meq tablet eff generic
POTASSIUM CHLORIDE (40MEQ/0.1L PIGGYBACK, 10MEQ TAB ER PRT, 8 MEQ CAPSULE ER, 8 MEQTABLET ER, 10 MEQ CAPSULE ER, 10MEQ/50MLPIGGYBACK, 2 MEQ/ML VIAL, 20MEQ/50MLPIGGYBACK, 20 MEQ PACKET, 20MEQ/15ML LIQUID,10 MEQ TABLET ER, 30MEQ/0.1L PIGGYBACK,20MEQ/0.1L PIGGYBACK, 2 MEQ/ML IV SOLN, 20 MEQTABLET ER, 20 MEQ TAB ER PRT, 40MEQ/15MLLIQUID, 10MEQ/0.1L PIGGYBACK)
generic
POTASSIUM CHLORIDE IN 0.9 % SODIUM CHLORIDE(20, 40)
generic
POTASSIUM CHLORIDE IN 5 % DEXTROSE IN WATER(40, 20, 30)
generic
PAGE 115 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
POTASSIUM CHLORIDE IN DEXTROSE 5 % AND 0.9 %SODIUM CHLORIDE (40, 20)
generic
POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.2 %SODIUM CHLORIDE (20, 10, 30, 40)
generic
POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.45 %SODIUM CHLORIDE (10, 20, 40, 30)
generic
POTASSIUM CHLORIDE IN LACTATED RINGERS AND 5% DEXTROSE (40, 20)
generic
potassium chloride-0.45% nacl 20 meq/l iv soln generic
potassium chloride/d5-0.3%nacl 20 meq/l iv soln generic
potassium phos in 0.9 % nacl 15mmol/250 plast. bag generic
potassium phos,m-basic-d-basic 3mmol/ml vial generic
PROFERRIN-FORTE TABLETiron heme polypeptide/folic acid
BRAND
PUREVIT DUALFE PLUS CAPSULEiron fumarate-iron polysacchar/folic acid/mv comb18
BRAND
ringers solution iv soln generic
ringers solution,lactated iv soln generic
SE-TAN PLUS CAPSULEiron fumarate-iron polysacchar/folic acid/mv comb18
BRAND
selenium 40 mcg/ml vial generic
SODIUM ACETATE (4, 2) generic
SODIUM BICARBONATE (1 MEQ/ML SYRINGE,0.5MEQ/ML SYRINGE, 0.9MEQ/ML SYRINGE, 1 MEQ/MLVIAL, 10MEQ/10ML SYRINGE, 0.5MEQ/ML VIAL)
generic
SODIUM CHLORIDE 0.45 % (0.45 PGGYBK PRT, 0.450.45 IV SOLN)
generic
sodium chloride 3 % 3 % iv soln generic
sodium chloride 5 % 5 % iv soln generic
sodium lactate 5 meq/ml vial generic
sodium phos,m-basic-d-basic 3mmol/ml vial generic
SYREX SODIUM CHL 0.9% SYR0.9 % sodium chloride
BRAND
TARON FORTE CAPSULEiron bisgly,pscmplx/ascorbate calc/b12/folic acid/calc-threo
BRAND
TL ICON CAPSULEferrous fumarate/ascorbic acid/b12-if/folic acid
BRAND
TL-HEM 150 CAPLET BRAND
PAGE 116 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
iron,carbonyl/docusate sodium/b12-if/folic acid/multivit-min
TRICON CAPSULEferrous fumarate/ascorbic acid/b12-if/folic acid
BRAND
TRIGELS-F FORTE SOFTGELferrous fumarate/ascorbic acid/cyanocobalamin/folic acid
BRAND
zinc chloride 1 mg/ml vial generic
ZINC SULFATE (1 MG/ML VIAL, 5 MG/ML VIAL,220(50)MG CAPSULE)
generic
AMINO ACIDS 15% SOLUTIONparenteral amino acid 15% combination no.1
BRAND
ascorbic acid 500 mg/ml vial generic
BAL-CARE DHA COMBO PACKprenatal vitamin no.81/sodium feredetate-ironpoly/fa/omega3
BRAND PA
cyanocobalamin (vitamin b-12) 1000mcg/ml vial generic
cysteine hcl 50 mg/ml vial generic
DEXTROSE 10 % IN WATER (10 10 IV SOLN, 10 10DEHP FR BG)
generic
dextrose 2.5 % in water 2.5 % iv soln generic
dextrose 20 % in water 20 % iv soln generic
dextrose 25 % in water 25 % syringe generic
dextrose 30 % in water 30 % iv soln generic
dextrose 40 % in water 40 % iv soln generic
DEXTROSE 5 % IN WATER (5 5 IV SOLN, 5 PGY VLPRT, 5 5 VIAL, 5 PGGYBK PRT)
generic
DEXTROSE 50 % IN WATER (50 50 IV SOLN, 50 50VIAL, 50 50 SYRGE)
generic
dextrose 70 % in water 70 % iv soln generic
DIALYVITE TABLETfolic acid/vitamin b comp and c
BRAND
ergocalciferol (vitamin d2) 50000 unit capsule generic
ethyl alcohol 98 % ampul generic
FLUOR-A-DAY (1 MG TABLET, 0.25 MG TAB, 0.5 MGTAB)sodium fluoride/xylitol
BRAND
FOLBEE PLUS TABLETfolic acid/vitamin b comp and c
BRAND
FOLIC ACID (5 MG/ML VIAL, 1 MG TABLET) generic
PAGE 117 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
FREAMINE III 10% IV SOLN.parenteral amino acid 10% combination no. 4
BRAND
INFED 100 MG/2 ML VIALiron dextran complex
BRANDPA
S Specialty Drug
levocarnitine (with sugar) 100 mg/ml solution generic
levocarnitine 330 mg tablet generic
LEVOMEFOLATE CALCIUM/SCHIZOCHYTRIUM ALGALOIL (7.5-90.314, 15-90.314)
generic
LIPOSYN III (20%, 10%, 30%)fat emulsions
BRAND
MEPHYTON 5 MG TABLETphytonadione
BRAND
MYNATAL PLUS CAPTABprenatal vitamins with calcium/ferrous fumarate/folic acid
BRAND
MYNATAL-Z CAPTABprenatal vitamins with calcium/ferrous fumarate/folic acid
BRAND
MYNEPHROCAPS SOFTGELvitamin b complex & vitamin c no.20/folic acid
BRAND
NEPHPLEX RX TABLETvitamin b complx no.3/folic acid/ascorbic acid/biotin/znox
BRAND
NEPHRO-VITE RX TABLETvitamin b complx no.3/folic acid/ascorbic acid/biotin
BRAND
NIVA-PLUS TABLETprenatal vits with calcium #74/ferrous fumarate/folic acid
BRAND
NUTRILIPID 20% IV FAT EMULSIONfat emulsions
BRAND
pedi mv #75/fluoride/iron 0.25-10/ml drops generic
PHYTONADIONE (10 MG/ML, 1MG/0.5ML) generic
PNV 29-1 TABLETprenatal vits with calcium #76/iron,carbonyl/folic acid
BRAND
pnv with ca,no.72/iron/fa 27 mg-1 mg tablet generic
pnv with ca,no.74/iron/fa 27 mg-1 mg tablet generic
PNV-SELECT TABLETprenatal vit with calcium no. 40/iron fumarate/fa cmb no.1
BRAND
PNV-VP-U CAPSULEprenatal vits without calc no5/ferrous fumarate/folic acid
BRAND
PREMASOL 10% IV SOLUTIONparenteral amino acid 10% combination no.7
BRAND
PAGE 118 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
PRENA1 CHEW TABLETprenatal vitamins combination no.42/folic acid
BRAND
PRENAPLUS TABLETprenatal vits with calcium #74/ferrous fumarate/folic acid
BRAND
PRETAB 29 MG-1 MG TABLETprenatal vits with calcium #78/ferrous fumarate/folic acid
BRAND
RENA-VITE RX TABLETvitamin b complx no.3/folic acid/ascorbic acid/biotin
BRAND
RENAL CAPS SOFTGELvitamin b complex & vitamin c no.20/folic acid
BRAND
RENO CAPS SOFTGELvitamin b complex & vitamin c no.20/folic acid
BRAND
ringers solution irrig soln generic
ringers solution,lactated irrig soln generic
sodium fluoride 0.25(0.55) tab chew generic
THERAPEUTIC VIT-MINERAL CAPmultivitamins with min no.7/folic acid
BRAND
thiamine hcl 100 mg/ml vial generic
THRIVITE RX TABLETprenatal vits with calcium #76/iron,carbonyl/folic acid
BRAND
TL G-FOL OS TABLETcalcium carb/mag oxide/vitamin d3/vit b12/fa/vit b6/boron
BRAND
TRAVASOL 10% SOLN VIAFLEXparenteral amino acid 10% combination no. 6
BRAND
ULTIMATE OB DHA COMBO PACKprenatal vitamin combo no.8/iron ps cmplx & aspgl/fa/dha
BRAND
VENA-BAL DHA COMBO PACKprenatal vitamin no.81/sodium feredetate-ironpoly/fa/omega3
BRAND PA
VIRT NATE TABLETprenatal vits with calcium #73/ferrous fumarate/folic acid
BRAND
VIRT-ADVANCE TABLETprenatal vitamin no.15/iron,carbonyl/folic acid/docusate sod
BRAND
VIRT-CAPS SOFTGELvitamin b complex & vitamin c no.20/folic acid
BRAND
VIRT-NATE DHA SOFTGELprenatal vitamins no.11/ferrous fumarate/folic acid/omega-3
BRAND
VIRT-NATE TABLETprenatal vits with calcium #73/ferrous fumarate/folic acid
BRAND
PAGE 119 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
VIRT-PN TABLETprenatal vit with calcium no. 40/iron fumarate/fa cmb no.1
BRAND
VIRT-VITE GT TABLETprenatal vitamin no.16/iron,carbonyl/folic acid/docusate sod
BRAND
VIRTPREX CAPSULEprenatal vit with calcium no.66/iron fum/folic acid/dss/dha
BRAND
VITAFOL-OB CAPLETprenatal vitamins comb 10/ferrous fumarate/folic acid
BRAND
VITAFOL-PN CAPLETprenatal vit with calcium cmb 11/ferrous fumarate/folic acid
BRAND
VOL-CARE RX TABLETvitamin b complx no.3/folic acid/ascorbic acid/biotin
BRAND
VOL-PLUS TABLETprenatal vits with calcium #74/ferrous fumarate/folic acid
BRAND
VP-VITE RX TABLETvitamin b complx no.3/folic acid/ascorbic acid/biotin
BRAND
PAGE 120 LAST UPDATED 02/2016
Index of covered drugs00.9 % SODIUM CHLORIDE 116
88-MOP 67
AA-HYDROCORT 81
A-METHAPRED 81
ABACAVIR SULFATE 45
ABACAVIR SULFATE/LAMIVUDINE 45
ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE 45
ABILIFY 41
ABILIFY DISCMELT 41
ABILIFY MAINTENA 41
ABIRATERONE ACETATE 32
ABRAXANE 33
ABSORICA 67
ACAMPROSATE CALCIUM 14
ACARBOSE 48
ACD 50
ACD-A 50
ACEBUTOLOL HCL 56
ACETAMINOPHEN WITH CODEINE PHOSPHATE 8
ACETASOL HC 102
ACETAZOLAMIDE 60
ACETAZOLAMIDE SODIUM 60
ACETIC ACID 102
ACETIC ACID/ALUMINUM ACETATE 103
ACETIC ACID/HYDROCORTISONE 103
ACETIC ACID/OXYQUINOLINE SULFATE 80
ACETYLCYSTEINE 109
ACITRETIN 67
ACLIDINIUM BROMIDE 106
ACTEMRA 95
ACTIMMUNE 95
ACTOPLUS MET XR 48
ACYCLOVIR 47
ACYCLOVIR SODIUM 46
ADACEL TDAP 96
ADALIMUMAB 94
ADAPALENE 67
ADCIRCA 108
ADEFOVIR DIPIVOXIL 43
ADEMPAS 108
ADENOSINE 56
ADO-TRASTUZUMAB EMTANSINE 37
ADRENALIN 106
ADRENALIN CHLORIDE 106
ADRIAMYCIN 33
ADRUCIL 32
ADVATE 52
ADVATE H 52
ADVATE L 52
ADVATE M 52
ADVATE SH 52
ADVATE UH 52
AERO OTIC HC 103
AFATINIB DIMALEATE 36
AFEDITAB CR 57
AFINITOR 36
AFINITOR DISPERZ 36
AGALSIDASE BETA 75
AKORN BALANCED SALT 99
ALAGESIC LQ 64
ALBENDAZOLE 38
ALBENZA 38
ALBUMIN HUMAN 97
ALBUTEIN 97
ALBUTEROL SULFATE 106
ALCLOMETASONE DIPROPIONATE 67
ALDURAZYME 74
ALENDRONATE SODIUM 97
ALFENTANIL HCL 8
ALFUZOSIN HCL 79
ALGLUCOSIDASE ALFA 75
ALIMTA 32
ALINIA 38
ALKERAN 31
ALLOPURINOL 29
ALLOPURINOL SODIUM 29
PAGE 121 LAST UPDATED 02/2016
ALMOTRIPTAN MALATE 29
ALOPRIM 29
ALOSETRON HCL 77
ALPHA-1-PROTEINASE INHIBITOR 110
ALPHAGAN P 102
ALPHANATE 52
ALPHAQUIN HP 67
ALPRAZOLAM 47
ALPRAZOLAM INTENSOL 47
ALPROSTADIL 58
ALTACAINE 99
ALTAFLUOR 99
ALTAVERA 84
ALTRETAMINE 31
ALUMINUM CHLORIDE 70
ALYACEN 84
AMANTADINE HCL 39
AMBRISENTAN 108
AMCINONIDE 67
AMETHIA 84
AMETHIA LO 84
AMETHYST 84
AMIFOSTINE CRYSTALLINE 33
AMIKACIN SULFATE 14
AMILORIDE HCL 61
AMILORIDE HCL/HYDROCHLOROTHIAZIDE 58
AMINO ACIDS 117
AMINOACETIC ACID 79
AMINOCAPROIC ACID 52
AMINOPHYLLINE 107
AMIODARONE HCL 56
AMITRIPTYLINE HCL 25
AMITRIPTYLINE HCL/CHLORDIAZEPOXIDE 24
AMLODIPINE BESYLATE 57
AMLODIPINE BESYLATE/ATORVASTATIN
CALCIUM 58
AMLODIPINE BESYLATE/BENAZEPRIL HCL 58
AMLODIPINE BESYLATE/VALSARTAN 58
AMLODIPINE
BESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDE
58
AMMONIUM LACTATE 70
AMNESTEEM 67
AMOXAPINE 26
AMOXICILLIN 19
AMOXICILLIN/POTASSIUM CLAVULANATE 19
AMPHOTERICIN B 27
AMPICILLIN SODIUM 19
AMPICILLIN SODIUM/SULBACTAM SODIUM 19
AMPICILLIN TRIHYDRATE 19
AMPYRA 65
AMYL NITRITE 62
ANAGRELIDE HCL 51
ANASPAZ 75
ANASTROZOLE 35
ANDROGEL 83
ANDROXY 83
ANECTINE 110
ANTHRALIN 69
ANTI-INHIBITOR COAGULANT COMPLEX 53
ANTIHEMOPHILIC FACTOR (FACTOR VIII)
RECOMB,B-DOMAIN DELETED 54
ANTIHEMOPHILIC FACTOR (FVIII) RECOMB,FULL
LENGTH (ALB-FREE) 53
ANTIHEMOPHILIC FACTOR (FVIII) RECOMBINANT,
FC FUSION PROTEIN 53
ANTIHEMOPHILIC FACTOR VIII RECOMBINANT, B-
DOMAIN TRUNCATED 53
ANTIHEMOPHILIC FACTOR VIII, HUMAN
RECOMBINANT 54
ANTIHEMOPHILIC FACTOR, HUMAN 53
ANTIHEMOPHILIC FACTOR, HUMAN/VON
WILLEBRAND FACTOR,HUMAN 53
ANTIPYRINE/BENZOCAINE 103
ANTIPYRINE/BENZOCAINE/GLYCERIN/ZINC
ACETATE 103
APEXICON 67
APEXICON E 67
APLIGRAF 98
APOKYN 39
APOMORPHINE HCL 39
APRACLONIDINE HCL 102
PAGE 122 LAST UPDATED 02/2016
APREPITANT 26
APRI 84
APRISO 96
APTIVUS 45
ARALAST 109
ARALAST NP 109
ARANELLE 84
ARBINOXA 104
ARCALYST 95
ARGATROBAN IN SODIUM CHLORIDE, ISO-
OSMOTIC 50
ARIPIPRAZOLE 41
ARMOUR THYROID 91
ARNUITY ELLIPTA 103
ARRANON 33
ARSENIC TRIOXIDE 35
ARTEMETHER/LUMEFANTRINE 38
ARZERRA 37
ASCOMP WITH CODEINE 8
ASCORBIC ACID 117
ASFOTASE ALFA 75
ASHLYNA 84
ASPIRIN/DIPYRIDAMOLE 54
ASTRAMORPH-PF 9
ATAZANAVIR SULFATE 46
ATENOLOL 56
ATENOLOL/CHLORTHALIDONE 58
ATOMOXETINE HCL 64
ATORVASTATIN CALCIUM 61
ATOVAQUONE 38
ATOVAQUONE/PROGUANIL HCL 38
ATRACURIUM BESYLATE 64
ATRIPLA 44
ATROPINE CARE 99
ATROPINE SULFATE 99
ATROVENT HFA 105
AUBRA 84
AURANOFIN 96
AURODEX 103
AUROGUARD 103
AVAR 67
AVASTIN 37
AVELOX IV 20
AVIANE 84
AVIDOXY 21
AVITA 67
AVITENE 98
AVONEX 65
AVONEX ADMINISTRATION PACK 65
AVONEX PEN 65
AXITINIB 36
AZASAN 93
AZATHIOPRINE 93
AZELASTINE HCL 104
AZITHROMYCIN 20
AZTREONAM 19
AZTREONAM LYSINE 106
AZURETTE 84
BB-DONNA 76
BACIIM 15
BACITRACIN 15
BACITRACIN/POLYMYXIN B SULFATE 101
BACLOFEN 110
BACTROBAN NASAL 15
BAL-CARE DHA 117
BALANCED SALT IRRIG SOLN NO.2 100
BALSALAZIDE DISODIUM 96
BALZIVA 84
BANZEL 23
BARACLUDE 43
BCG LIVE 35
BEBULIN 52
BEBULIN VH IMMUNO 52
BECAPLERMIN 72
BECLOMETHASONE DIPROPIONATE 104
BEDAQUILINE FUMARATE 30
BEKYREE 84
BELATACEPT 94
BELIMUMAB 95
BENAZEPRIL HCL 55
PAGE 123 LAST UPDATED 02/2016
BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE 58
BENDAMUSTINE HCL 31
BENEFIX 52
BENLYSTA 95
BENOXINATE HCL/FLUORESCEIN SODIUM 100
BENZEPRO 67
BENZONATATE 109
BENZOYL PEROXIDE 68
BENZOYL PEROXIDE MICROSPHERES 73
BENZPHETAMINE HCL 64
BENZTROPINE MESYLATE 39
BETAINE 75
BETAMETHASONE ACETATE/BETAMETHASONE
SODIUM PHOSPHATE 81
BETAMETHASONE DIPROPIONATE 67
BETAMETHASONE DIPROPIONATE/PROPYLENE
GLYCOL 67
BETAMETHASONE VALERATE 68
BETAXOLOL HCL 102
BETHANECHOL CHLORIDE 80
BEVACIZUMAB 37
BEXAROTENE 38
BEXXAR 37
BICALUTAMIDE 32
BICNU 31
BIMATOPROST 102
BIOGLO 99
BISACODYL/SODIUM CHLOR/SODIUM
BICARB/POTASSIUM CHL/PEG 3350 77
BISOPROLOL FUMARATE 56
BISOPROLOL
FUMARATE/HYDROCHLOROTHIAZIDE 58
BIVIGAM 95
BLISOVI 24 FE 84
BLISOVI FE 84
BOCEPREVIR 44
BOSENTAN 108
BOSULIF 36
BOSUTINIB 36
BP 10-1 68
BP-50% UREA 68
BPO 68
BREO ELLIPTA 109
BRIELLYN 84
BRILINTA 54
BRIMONIDINE TARTRATE 102
BROMFENAC SODIUM 101
BROMOCRIPTINE MESYLATE 39
BSS 100
BUDEPRION XL 24
BUDESONIDE 104
BUDESONIDE/FORMOTEROL FUMARATE 110
BUFFERED LIDOCAINE 12
BUMETANIDE 60
BUPHENYL 75
BUPIVACAINE HCL 13
BUPIVACAINE HCL/DEXTROSE-WATER/PF 12
BUPIVACAINE HCL/EPINEPHRINE 13
BUPIVACAINE HCL/EPINEPHRINE/PF 12
BUPIVACAINE HCL/PF 13
BUPRENORPHINE HCL 14
BUPRENORPHINE HCL/NALOXONE HCL 14
BUPROBAN 14
BUPROPION HCL 24
BUSPIRONE HCL 47
BUSULFAN 31
BUSULFEX 31
BUTALBITAL/ACETAMINOPHEN 65
BUTALBITAL/ACETAMINOPHEN/CAFFEINE 65
BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEIN
E PHOSPHATE 9
BUTALBITAL/ASPIRIN/CAFFEINE 64
BUTOCONAZOLE NITRATE 28
BUTORPHANOL TARTRATE 9
BYDUREON 48
BYDUREON PEN 48
BYETTA 48
CCABERGOLINE 92
CAFFEINE CITRATED 107
CAFFEINE/SODIUM BENZOATE 111
PAGE 124 LAST UPDATED 02/2016
CALCIPOTRIENE 68
CALCIPOTRIENE/BETAMETHASONE
DIPROPIONATE 68
CALCITONIN,SALMON,SYNTHETIC 97
CALCITRENE 68
CALCITRIOL 97
CALCIUM ACETATE 81
CALCIUM CARB/MAG OXIDE/VITAMIN D3/VIT
B12/FA/VIT B6/BORON 119
CALCIUM CHLORIDE 112
CALCIUM GLUCONATE 112
CAMILA 90
CAMRESE 84
CAMRESE LO 85
CANAGLIFLOZIN 48
CANAGLIFLOZIN/METFORMIN HCL 48
CANAKINUMAB/PF 95
CANASA 96
CANCIDAS 27
CANDESARTAN CILEXETIL 55
CANDESARTAN
CILEXETIL/HYDROCHLOROTHIAZIDE 58
CAPACET 64
CAPECITABINE 32
CAPRELSA 36
CAPTOPRIL 55
CAPTOPRIL/HYDROCHLOROTHIAZIDE 58
CARAFATE 78
CARB-O-PHILIC 68
CARBACHOL 102
CARBAGLU 112
CARBAMAZEPINE 23
CARBIDOPA 40
CARBIDOPA/LEVODOPA 40
CARBIDOPA/LEVODOPA/ENTACAPONE 39
CARBINOXAMINE MALEATE 105
CARBOCAINE 13
CARBOPLATIN 33
CARBOPROST TROMETHAMINE 80
CARDIOPLEGIC SOLUTION NO.1 58
CARGLUMIC ACID 112
CARISOPRODOL 110
CARMUSTINE 31
CARTEOLOL HCL 102
CARTIA XT 57
CARVEDILOL 56
CASPOFUNGIN ACETATE 27
CAYSTON 106
CAZIANT 85
CEFACLOR 17
CEFADROXIL 17
CEFAZOLIN SODIUM 17
CEFAZOLIN SODIUM IN 0.9 % SODIUM
CHLORIDE 18
CEFAZOLIN SODIUM/DEXTROSE 5 % IN WATER 18
CEFAZOLIN SODIUM/DEXTROSE, ISO-OSMOTIC 18
CEFDINIR 18
CEFDITOREN PIVOXIL 18
CEFEPIME HCL 18
CEFEPIME HCL/DEXTROSE, ISO-OSMOTIC 18
CEFIXIME 18
CEFOTAXIME SODIUM 18
CEFOTETAN DISODIUM 18
CEFOXITIN SODIUM 18
CEFOXITIN SODIUM/DEXTROSE, ISO-OSMOTIC 18
CEFPODOXIME PROXETIL 18
CEFPROZIL 18
CEFTAZIDIME 18
CEFTIBUTEN 18
CEFTRIAXONE SODIUM 18
CEFTRIAXONE SODIUM/DEXTROSE, ISO-
OSMOTIC 18
CEFUROXIME AXETIL 18
CEFUROXIME SODIUM 18
CEFUROXIME SODIUM/DEXTROSE, ISO-
OSMOTIC 18
CELEBREX 5
CELECOXIB 5
CELLCEPT 93
CELONTIN 22
CEM-UREA 68
CENTERGY 109
PAGE 125 LAST UPDATED 02/2016
CENTRATEX 112
CEPHALEXIN 18
CERITINIB 37
CERUBIDINE 33
CETUXIMAB 37
CEVIMELINE HCL 66
CHANTIX 14
CHATEAL 85
CHEMET 111
CHENODAL 76
CHENODIOL 76
CHLORAMBUCIL 31
CHLORAMPHENICOL SOD SUCC 15
CHLORDIAZEPOXIDE HCL 47
CHLORDIAZEPOXIDE/CLIDINIUM BROMIDE 76
CHLORHEXIDINE GLUCONATE 66
CHLOROPROCAINE HCL/PF 13
CHLOROQUINE PHOSPHATE 38
CHLOROTHIAZIDE 61
CHLOROTHIAZIDE SODIUM 61
CHLORPHENIRAMINE MALEATE/PHENYLEPHRINE
HCL 109
CHLORPROMAZINE HCL 40
CHLORTHALIDONE 61
CHLORZOXAZONE 110
CHOLESTYRAMINE (WITH SUGAR) 62
CHOLESTYRAMINE/ASPARTAME 62
CHOLINE SALICYLATE/MAGNESIUM SALICYLATE 5
CHORIONIC GONADOTROPIN, HUMAN 83
CHROMIC CHLORIDE 112
CICLODAN 27
CICLOPIROX 27
CICLOPIROX OLAMINE 27
CICLOPIROX/UREA/CAMPHOR/MENTHOL/EUCALY
PTOL 27
CIDOFOVIR 42
CILOSTAZOL 54
CIMETIDINE 77
CIMETIDINE HCL 77
CINACALCET HCL 92
CIPRO 20
CIPRODEX 103
CIPROFLOXACIN 20
CIPROFLOXACIN HCL 100
CIPROFLOXACIN HCL/DEXAMETHASONE 103
CIPROFLOXACIN LACTATE 20
CIPROFLOXACIN LACTATE/DEXTROSE 5 % IN
WATER 21
CIPROFLOXACIN/CIPROFLOXACIN HCL 21
CISPLATIN 33
CITALOPRAM HYDROBROMIDE 25
CITRATE DEXTROSE SOLUTION 50
CITRATE PHOSPHATE DEXTROS SOLN 50
CITRIC ACID/GLUCONOLACTONE/MAGNESIUM
CARBONATE 80
CITRIC ACID/SODIUM CITRATE 81
CLADRIBINE 32
CLARAVIS 68
CLARIS 68
CLARITHROMYCIN 20
CLEANSING WASH 68
CLEMASTINE FUMARATE 104
CLINDACIN ETZ 68
CLINDACIN P 68
CLINDAMYCIN HCL 15
CLINDAMYCIN PALMITATE HCL 15
CLINDAMYCIN PHOSPHATE 68
CLINDAMYCIN PHOSPHATE/BENZOYL
PEROXIDE 71
CLINDAMYCIN PHOSPHATE/DEXTROSE 5 % IN
WATER 15
CLOBAZAM 22
CLOBETASOL PROPIONATE 69
CLOBETASOL PROPIONATE/EMOLLIENT BASE 68
CLODAN 68
CLOMIPRAMINE HCL 26
CLONAZEPAM 47
CLONIDINE 54
CLONIDINE HCL 63
CLONIDINE HCL/CHLORTHALIDONE 59
CLONIDINE HCL/PF 54
CLOPIDOGREL BISULFATE 54
PAGE 126 LAST UPDATED 02/2016
CLORAZEPATE DIPOTASSIUM 47
CLORPRES 59
CLOTRIMAZOLE/BETAMETHASONE
DIPROPIONATE 69
CLOZAPINE 42
COAGULATION FACTOR VIIA (RECOMBINANT) 53
COAL TAR 98
COARTEM 38
COCAINE HCL 69
CODEINE
PHOSPHATE/BUTALBITAL/ASPIRIN/CAFFEINE 9
CODEINE SULFATE 9
COLCHICINE 29
COLCHICINE/PROBENECID 29
COLCRYS 29
COLESTIPOL HCL 62
COLISTIN (AS COLISTIMETHATE SODIUM) 15
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 72
COLOCORT 96
COMBIVENT RESPIMAT 109
COMPLERA 44
COMPOUND 347 13
COMPRO 26
COPAXONE 65
CORIFACT 52
CORLANOR 59
CORLOPAM 62
CORMAX 69
CORTANE-B 103
CORTICOTROPIN 83
CORTIFOAM 96
CORTISONE ACETATE 81
CORVITA 150 112
COSYNTROPIN 82
CREON 75
CRIXIVAN 46
CRIZOTINIB 37
CROMOLYN SODIUM 109
CROTAMITON 39
CRYSELLE 85
CULT SKIN SUBST,HUMAN-BOVINE 98
CUPRIC CHLORIDE 112
CUPRIMINE 80
CYANOCOBALAMIN (VITAMIN B-12) 117
CYCLAFEM 85
CYCLOBENZAPRINE HCL 110
CYCLOPENTOLATE HCL 100
CYCLOPHOSPHAMIDE 31
CYCLOSPORINE 101
CYCLOSPORINE, MODIFIED 94
CYPROHEPTADINE HCL 104
CYRED 85
CYSTADANE 75
CYSTAGON 75
CYSTARAN 100
CYSTEAMINE BITARTRATE 75
CYSTEAMINE HCL 100
CYSTEINE HCL 117
CYTARABINE 32
CYTARABINE/PF 32
CYTRA-2 80
CYTRA-3 80
CYTRA-K 80
DDABIGATRAN ETEXILATE MESYLATE 51
DABRAFENIB MESYLATE 37
DACARBAZINE 31
DACTINOMYCIN 33
DALFAMPRIDINE 65
DANAZOL 83
DANTROLENE SODIUM 110
DAPSONE 30
DARAPRIM 38
DARUNAVIR ETHANOLATE 46
DASATINIB 36
DASETTA 85
DAUNORUBICIN CITRATE LIPOSOMAL 31
DAUNORUBICIN HCL 33
DAUNOXOME 31
DAYSEE 85
DEBACTEROL 66
PAGE 127 LAST UPDATED 02/2016
DEBLITANE 90
DECITABINE 33
DEFERASIROX 111
DEFERIPRONE 111
DEFEROXAMINE MESYLATE 98
DELAVIRDINE MESYLATE 44
DELFLEX WITH 1.5% DEXTROSE 112
DELFLEX WITH 2.5% DEXTROSE 112
DELFLEX WITH 4.25% DEXTROSE 112
DELTASONE 81
DELYLA 85
DEMECLOCYCLINE HCL 21
DEMSER 59
DEPADE 14
DEPO-PROVERA 90
DERMAZENE 69
DESIPRAMINE HCL 26
DESLORATADINE 104
DESMOPRESSIN ACETATE 83
DESMOPRESSIN ACETATE (NON-
REFRIGERATED) 82
DESOGESTREL-ETHINYL ESTRADIOL 90
DESOGESTREL-ETHINYL ESTRADIOL/ETHINYL
ESTRADIOL 90
DESONIDE 69
DESOXIMETASONE 69
DEXAMETHASONE 81
DEXAMETHASONE INTENSOL 81
DEXAMETHASONE SOD PHOSPHATE 101
DEXAMETHASONE SODIUM PHOSPHATE/PF 81
DEXEDRINE 63
DEXMEDETOMIDINE HCL 98
DEXMETHYLPHENIDATE HCL 63
DEXPANTHENOL 77
DEXRAZOXANE HCL 33
DEXTRAN 40 IN 0.9 % SODIUM CHLORIDE 98
DEXTRAN 40/DEXTROSE 5 % IN WATER 98
DEXTROAMPHETAMINE SULF-
SACCHARATE/AMPHETAMINE SULF-
ASPARTATE 63
DEXTROAMPHETAMINE SULFATE 63
DEXTROMETHORPHAN HBR/QUINIDINE
SULFATE 64
DEXTROSE 10 % AND 0.2 % SODIUM
CHLORIDE 112
DEXTROSE 10 % AND 0.45 % SODIUM
CHLORIDE 112
DEXTROSE 10 % AND 0.9 % SODIUM
CHLORIDE 112
DEXTROSE 10 % IN WATER 117
DEXTROSE 2.5 % AND 0.45 % SODIUM
CHLORIDE 112
DEXTROSE 2.5 % IN WATER 117
DEXTROSE 20 % IN WATER 117
DEXTROSE 25 % IN WATER 117
DEXTROSE 30 % IN WATER 117
DEXTROSE 40 % IN WATER 117
DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE 112
DEXTROSE 5 % AND 0.3 % SODIUM CHLORIDE 112
DEXTROSE 5 % AND 0.45 % SODIUM
CHLORIDE 112
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE 112
DEXTROSE 5 % IN LACTATED RINGERS 113
DEXTROSE 5 % IN WATER 117
DEXTROSE 5% IN RINGERS 112
DEXTROSE 50 % IN WATER 117
DEXTROSE 70 % IN WATER 117
DEXTROSE-WATER/SODIUM CITRATE/CITRIC
ACID 50
DIALYVITE 117
DIATRIZOATE MEGLUMINE/DIATRIZOATE
SODIUM 98
DIAZEPAM 47
DIAZOXIDE 50
DIBENZYLINE 55
DICLOFENAC POTASSIUM 5
DICLOFENAC SODIUM 101
DICLOFENAC SODIUM/MISOPROSTOL 5
DICLOXACILLIN SODIUM 19
DICYCLOMINE HCL 76
DIDANOSINE 45
DIETHYLPROPION HCL 64
PAGE 128 LAST UPDATED 02/2016
DIFIL-G 400 107
DIFLORASONE DIACETATE 69
DIFLORASONE DIACETATE/EMOLLIENT BASE 67
DIFLUNISAL 5
DIGITEK 59
DIGOX 59
DIGOXIN 59
DIHYDROCODEINE
BITARTRATE/ACETAMINOPHEN/CAFFEINE 9
DIHYDROCODEINE
BITARTRATE/ASPIRIN/CAFFEINE 9
DIHYDROERGOTAMINE MESYLATE 29
DILANTIN 23
DILT-XR 57
DILTIAZEM HCL 58
DIMENHYDRINATE 26
DIMETHYL FUMARATE 66
DIOXYBENZONE/PADIMATE O/HYDROQUINONE 71
DIPHENHYDRAMINE HCL 104
DIPHENOXYLATE HCL/ATROPINE SULFATE 77
DIPHTHERIA,PERTUSSIS(ACELL),TETANUS
VACCINE/PF 96
DIPYRIDAMOLE 54
DISKETS 6
DISULFIRAM 14
DIVALPROEX SODIUM 22
DOBUTAMINE HCL 59
DOBUTAMINE HCL/DEXTROSE 5 % IN WATER 59
DOCETAXEL 33
DOFETILIDE 56
DOLUTEGRAVIR SODIUM 44
DONEPEZIL HCL 24
DOPAMINE HCL 59
DOPAMINE HCL/DEXTROSE 5 % IN WATER 59
DORNASE ALFA 109
DORZOLAMIDE HCL 102
DORZOLAMIDE HCL/TIMOLOL MALEATE 102
DOXAPRAM HCL 109
DOXAZOSIN MESYLATE 55
DOXEPIN HCL 26
DOXERCALCIFEROL 97
DOXIL 34
DOXORUBICIN HCL 34
DOXORUBICIN HCL PEGYLATED LIPOSOMAL 34
DOXYCYCLINE HYCLATE/EYELID CLNS
NO.3/EYELID EMOLLIENT NO.1 21
DOXYCYCLINE MONOHYDRATE 21
DRITHOCREME HP 69
DRONABINOL 26
DROPERIDOL 40
DROXIA 32
DROXIDOPA 60
DRYSOL 69
DULERA 109
DULOXETINE HCL 65
DURAMORPH 9
DUTASTERIDE 79
DUTASTERIDE/TAMSULOSIN HCL 79
EE.E.S. 200 20
E.E.S. 400 20
ECHOTHIOPHATE IODIDE 102
ECONAZOLE NITRATE 27
ECULIZUMAB 99
ED-SPAZ 76
EDROPHONIUM CHLORIDE 30
EDURANT 44
EFAVIRENZ 45
EFAVIRENZ/EMTRICITABINE/TENOFOVIR
DISOPROXIL FUMARATE 44
EFFER-K 113
EFFIENT 54
EGRIFTA 93
ELAPRASE 75
ELASTIDERM 71
ELECTROLYTE-48 SOLUTION/DEXTROSE 5 % IN
WATER 113
ELELYSO 75
ELINEST 85
ELIPHOS 81
ELITEK 33
PAGE 129 LAST UPDATED 02/2016
ELMIRON 80
ELOCTATE 53
ELOXATIN 34
ELTROMBOPAG OLAMINE 52
ELVITEGRAVIR/COBICISTAT/EMTRICITABINE/TEN
OFOVIR 44
EMCYT 32
EMEND 26
EMOQUETTE 85
EMTRICITABINE 45
EMTRICITABINE/RILPIVIRINE HCL/TENOFOVIR
DISOPROXIL FUMARATE 44
EMTRICITABINE/TENOFOVIR DISOPROXIL
FUMARATE 45
EMTRIVA 45
ENALAPRIL MALEATE 55
ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE 59
ENALAPRILAT DIHYDRATE 55
ENBREL 93
ENDO-AVITENE 98
ENDOCET 9
ENDODAN 9
ENDOMETRIN 90
ENFLURANE 13
ENFUVIRTIDE 45
ENLON 30
ENOXAPARIN SODIUM 50
ENPRESSE 85
ENSKYCE 85
ENTACAPONE 39
ENTECAVIR 43
ENULOSE 77
ENZALUTAMIDE 32
EPHEDRINE SULFATE 59
EPINASTINE HCL 101
EPINEPHRINE 106
EPINEPHRINE HCL/PF 106
EPINEPHRINE/PF 106
EPIPEN 2-PAK 106
EPIPEN JR 2-PAK 106
EPIRUBICIN HCL 34
EPITOL 23
EPIVIR 45
EPIVIR HBV 43
EPLERENONE 61
EPOETIN ALFA 52
EPOPROSTENOL SODIUM (ARGININE) 108
EPOPROSTENOL SODIUM (GLYCINE) 108
EPROSARTAN MESYLATE 55
EPTIFIBATIDE 54
EPZICOM 45
ERBITUX 37
ERGOCALCIFEROL (VITAMIN D2) 117
ERGOLOID MESYLATES 24
ERGOTAMINE TARTRATE/CAFFEINE 29
ERIVEDGE 36
ERLOTINIB HCL 37
ERRIN 91
ERY 69
ERY-TAB 20
ERYGEL 69
ERYPED 200 20
ERYPED 400 20
ERYTHROCIN STEARATE 20
ERYTHROMYCIN BASE 100
ERYTHROMYCIN BASE/BENZOYL PEROXIDE 69
ERYTHROMYCIN BASE/ETHYL ALCOHOL 69
ERYTHROMYCIN ETHYLSUCCINATE 20
ERYTHROMYCIN
ETHYLSUCCINATE/SULFISOXAZOLE ACETYL 20
ERYTHROMYCIN STEARATE 20
ESCITALOPRAM OXALATE 25
ESGIC 64
ESMOLOL HCL 56
ESOMEPRAZOLE MAGNESIUM 78
ESOMEPRAZOLE SODIUM 78
ESOMEPRAZOLE STRONTIUM 78
ESTARYLLA 85
ESTAZOLAM 110
ESTRADIOL 90
ESTRADIOL VALERATE 85
ESTRADIOL/NORETHINDRONE ACETATE 88
PAGE 130 LAST UPDATED 02/2016
ESTRAMUSTINE PHOSPHATE SODIUM 32
ESTROGENS,
CONJUGATED/MEDROXYPROGESTERONE
ACETATE 89
ESTROGENS,ESTERIFIED 87
ESTROPIPATE 88
ESZOPICLONE 110
ETANERCEPT 93
ETHACRYNATE SODIUM 61
ETHAMBUTOL HCL 30
ETHINYL ESTRADIOL/DROSPIRENONE 90
ETHOSUXIMIDE 22
ETHOTOIN 23
ETHYL ALCOHOL 117
ETHYL CHLORIDE 69
ETHYNODIOL DIACETATE-ETHINYL ESTRADIOL 90
ETIDRONATE DISODIUM 97
ETODOLAC 5
ETOMIDATE 13
ETONOGESTREL 91
ETOPOSIDE 35
ETRAVIRINE 44
EUFLEXXA 98
EURAX 39
EVEROLIMUS 95
EXEMESTANE 35
EXENATIDE 48
EXENATIDE MICROSPHERES 48
EXJADE 111
EXOTIC-HC 103
EXTAVIA 66
EZ FLU 2015-2016 (FLUVIRIN) 96
EZETIMIBE 62
EZOGABINE 22
FFABRAZYME 75
FACTOR IX 53
FACTOR IX COMPLEX HUMAN 54
FACTOR IX COMPLEX, PROTHROMBIN CPLX
CONC(PCC) NO.4, 3-FACTOR 53
FACTOR IX COMPLEX, PROTHROMBIN CPLX
CONC(PCC) NO.6, 3-FACTOR 52
FACTOR IX HUMAN RECOMBINANT 52
FACTOR IX HUMAN RECOMBINANT, THREONINE
148 53
FACTOR XIII 52
FACTOR XIII A-SUBUNIT, RECOMBINANT 54
FALMINA 86
FAMCICLOVIR 46
FAMOTIDINE 77
FAMOTIDINE/PF 77
FARESTON 32
FAT EMULSIONS 118
FE 90 PLUS 113
FE C PLUS 113
FEBUXOSTAT 29
FEIBA NF 53
FEIBA VH IMMUNO 53
FELBAMATE 23
FELODIPINE 57
FEM PH 80
FENOFIBRATE 61
FENOFIBRATE NANOCRYSTALLIZED 61
FENOFIBRATE,MICRONIZED 61
FENOFIBRIC ACID 61
FENOFIBRIC ACID (CHOLINE) 61
FENOLDOPAM MESYLATE 62
FENOPROFEN CALCIUM 5
FENTANYL 6
FENTANYL CITRATE 9
FENTANYL CITRATE IN 0.9 % SODIUM
CHLORIDE/PF 9
FENTANYL CITRATE/BUPIVACAINE HCL IN 0.9 %
SODIUM CHLORIDE/PF 9
FENTANYL CITRATE/PF 12
FEROCON 113
FEROTRINSIC 113
FERRAPLUS 90 113
FERREX 150 FORTE 113
FERREX 150 FORTE PLUS 113
FERREX 28 113
PAGE 131 LAST UPDATED 02/2016
FERRIC SUBSULFATE 53
FERRIPROX 111
FERROCITE PLUS 113
FERROGELS FORTE 113
FERROUS FUMARATE/ASCORBIC ACID/B12-
IF/FOLIC ACID 117
FERROUS FUMARATE/ASCORBIC
ACID/CYANOCOBALAMIN/FOLIC ACID 117
FERROUS FUMARATE/ASCORBIC
ACID/CYANOCOBALAMIN/STOMACH CONC 113
FERROUS FUMARATE/FOLIC ACID 113
FERROUS FUMARATE/FOLIC
ACID/MULTIVITAMINS WITH MIN NO. 15 112
FEXOFENADINE HCL/PSEUDOEPHEDRINE HCL 109
FIBRINOGEN 54
FINASTERIDE 79
FINGOLIMOD HCL 66
FIRAZYR 93
FIRST-BXN 27
FIRST-LANSOPRAZOLE 78
FIRST-MOUTHWASH BLM 66
FIRST-OMEPRAZOLE 78
FLAVOXATE HCL 79
FLEBOGAMMA DIF 95
FLECAINIDE ACETATE 56
FLOXURIDINE 33
FLUCAINE 100
FLUCONAZOLE 27
FLUCONAZOLE IN DEXTROSE, ISO-OSMOTIC 27
FLUCONAZOLE IN SODIUM CHLORIDE, ISO-
OSMOTIC 27
FLUCYTOSINE 28
FLUDARABINE PHOSPHATE 34
FLUDROCORTISONE ACETATE 81
FLUMAZENIL 98
FLUNISOLIDE 104
FLUOCINOLONE ACETONIDE 69
FLUOCINOLONE ACETONIDE OIL 103
FLUOCINOLONE ACETONIDE/SHOWER CAP 69
FLUOCINONIDE 69
FLUOCINONIDE/EMOLLIENT BASE 69
FLUOR-A-DAY 117
FLUOR-I-STRIP AT 100
FLUORESCEIN SODIUM 100
FLUORESCITE 100
FLUORETS 100
FLUOROMETHOLONE 102
FLUOROURACIL 33
FLUOXETINE HCL 25
FLUOXYMESTERONE 83
FLUPHENAZINE DECANOATE 40
FLUPHENAZINE HCL 40
FLURAZEPAM HCL 111
FLURBIPROFEN 5
FLURBIPROFEN SODIUM 102
FLUROX 100
FLUTAMIDE 32
FLUTICASONE FUROATE 103
FLUTICASONE FUROATE/VILANTEROL
TRIFENATATE 109
FLUTICASONE PROPIONATE 104
FLUVASTATIN SODIUM 61
FLUVOXAMINE MALEATE 25
FOCALGIN DSS 113
FOLBEE PLUS 117
FOLIC ACID 117
FOLIC ACID/VITAMIN B COMP AND C 117
FOLIVANE-F 113
FOLIVANE-PLUS 113
FOLLITROPIN ALFA, RECOMB 83
FOLOTYN 33
FOMEPIZOLE 98
FONDAPARINUX SODIUM 50
FORANE 13
FORMA-RAY 69
FORMADON 98
FORMALDEHYDE 98
FORMOTEROL FUMARATE 106
FORTEO 97
FORTICAL 97
FOSAMPRENAVIR CALCIUM 46
FOSCARNET SODIUM 42
PAGE 132 LAST UPDATED 02/2016
FOSINOPRIL SODIUM 55
FOSINOPRIL SODIUM/HYDROCHLOROTHIAZIDE 59
FOSPHENYTOIN SODIUM 23
FREAMINE III 117
FUL-GLO 100
FUROSEMIDE 61
FUSILEV 34
FUZEON 45
GGABAPENTIN 22
GABITRIL 22
GABLOFEN 110
GALANTAMINE HBR 24
GALSULFASE 75
GAMMAGARD LIQUID 95
GAMMAPLEX 95
GAMUNEX 95
GAMUNEX-C 95
GANCICLOVIR SODIUM 43
GARAMYCIN 100
GASTROCROM 77
GATIFLOXACIN 100
GAVILYTE-H AND BISACODYL 77
GEMCITABINE HCL 33
GEMFIBROZIL 61
GENERLAC 78
GENGRAF 94
GENTAK 100
GENTAMICIN SULFATE 100
GENTAMICIN SULFATE IN SODIUM CHLORIDE,
ISO-OSMOTIC 15
GENTAMICIN SULFATE/PF 15
GEODON 41
GIANVI 86
GILDAGIA 86
GILDESS 86
GILDESS 24 FE 86
GILDESS FE 86
GILENYA 66
GILOTRIF 36
GLATIRAMER ACETATE 66
GLATOPA 66
GLEEVEC 36
GLEOSTINE 31
GLIMEPIRIDE 48
GLIPIZIDE 48
GLIPIZIDE/METFORMIN HCL 48
GLUCAGEN 49
GLUCAGON EMERGENCY KIT 50
GLUCAGON HCL 50
GLUCAGON,HUMAN RECOMBINANT 50
GLUTARALDEHYDE 98
GLYBURIDE 48
GLYBURIDE,MICRONIZED 48
GLYBURIDE/METFORMIN HCL 48
GLYCEROL PHENYLBUTYRATE 75
GLYCINE UROLOGIC SOLUTION 80
GLYCINE/SODIUM/WATER FOR
INJECTION,STERILE/SODIUM HYDROXIDE 98
GLYCOPYRROLATE 76
GLYDO 69
GONAL-F RFF 82
GONAL-F RFF REDI-JECT 83
GRANISETRON HCL 27
GRANISETRON HCL/PF 27
GRANISOL 27
GRISEOFULVIN ULTRAMICROSIZE 28
GRISEOFULVIN, MICROSIZE 28
GRX HICORT 25 81
GUAIFENESIN/DYPHYLLINE 107
GUANFACINE HCL 63
GUANIDINE HCL 30
GYNAZOLE 1 28
HH.P. ACTHAR 83
HALOBETASOL PROPIONATE 70
HALOBETASOL PROPIONATE/AMMONIUM
LACTATE 70
HALONATE 70
HALONATE PAC 70
PAGE 133 LAST UPDATED 02/2016
HALOPERIDOL 40
HALOPERIDOL DECANOATE 40
HALOPERIDOL LACTATE 40
HARVONI 43
HEATHER 91
HECORIA 94
HECTOROL 97
HELIXATE FS 53
HEMABATE 80
HEMATINIC PLUS 113
HEMATINIC WITH FOLIC ACID 113
HEMATOGEN 113
HEMATOGEN FA 113
HEMATOGEN FORTE 113
HEMETAB 114
HEMIN 99
HEMMOREX-HC 81
HEMRIL 82
HEPARIN SODIUM,PORCINE 51
HEPARIN SODIUM,PORCINE IN 0.45 % SODIUM
CHLORIDE 51
HEPARIN SODIUM,PORCINE IN 0.9 % SODIUM
CHLORIDE 51
HEPARIN SODIUM,PORCINE IN 0.9 % SODIUM
CHLORIDE/PF 51
HEPARIN SODIUM,PORCINE/DEXTROSE 5 % IN
WATER 51
HEPARIN SODIUM,PORCINE/PF 51
HERCEPTIN 37
HETLIOZ 111
HEXALEN 31
HISTRELIN ACETATE 93
HIZENTRA 95
HOMATROPAIRE 100
HOMATROPINE HBR 100
HUMALOG KWIKPEN U-200 50
HUMATE-P 53
HUMIRA 94
HUMIRA PEDIATRIC CROHN'S 94
HUMIRA PEN 94
HUMIRA PEN CROHN'S-UC-HS 94
HUMIRA PEN PSORIASIS 94
HUMULIN R U-500 50
HYALURONATE SODIUM 98
HYDRALAZINE HCL 62
HYDROCHLOROTHIAZIDE 61
HYDROCODONE
BITARTRATE/ACETAMINOPHEN 12
HYDROCODONE BITARTRATE/HOMATROPINE
METHYLBROMIDE 110
HYDROCODONE
POLISTIREX/CHLORPHENIRAMINE POLISTIREX109
HYDROCODONE/IBUPROFEN 12
HYDROCORTISONE 97
HYDROCORTISONE ACETATE 96
HYDROCORTISONE ACETATE/ALOE VERA 70
HYDROCORTISONE ACETATE/LIDOCAINE
HCL/ALOE VERA 70
HYDROCORTISONE ACETATE/PRAMOXINE HCL 72
HYDROCORTISONE
ACETATE/PRAMOXINE/EMOLLIENT/PRAMOXINE
COMB#1 70
HYDROCORTISONE BUTYRATE 70
HYDROCORTISONE BUTYRATE/EMOLLIENT
BASE 70
HYDROCORTISONE SOD SUCCINATE 81
HYDROCORTISONE VALERATE 70
HYDROCORTISONE/IODOQUINOL 70
HYDROCORTISONE/MINERAL
OIL/PETROLATUM,WHITE 70
HYDROCORTISONE/PRAMOXINE
HCL/CHLOROXYLENOL 103
HYDROCORTISONE/PRAMOXINE
HCL/CHLOROXYLENOL/WATER 103
HYDROMORPHONE HCL 10
HYDROMORPHONE HCL/PF 10
HYDROQUINONE 71
HYDROQUINONE MICROSPHERES 70
HYDROQUINONE/FERRIC OXIDE 71
HYDROXYCHLOROQUINE SULFATE 38
HYDROXYPROGESTERONE CAPROATE 91
HYDROXYUREA 33
PAGE 134 LAST UPDATED 02/2016
HYDROXYZINE HCL 104
HYDROXYZINE PAMOATE 104
HYOPHEN 15
HYOSCYAMINE SULFATE 76
HYOSYNE 76
HYPERCARE 70
HYPERRHO S-D 95
HYPROMELLOSE 101
IIBANDRONATE SODIUM 97
IBRANCE 36
IBRUTINIB 36
IBUPROFEN 5
IBUPROFEN/OXYCODONE HCL 10
IBUTILIDE FUMARATE 56
IC GREEN 98
ICATIBANT ACETATE 93
ICLUSIG 36
ICOSAPENT ETHYL 62
IDARUBICIN HCL 34
IDELALISIB 37
IDURSULFASE 75
IFOSFAMIDE 31
IFOSFAMIDE/MESNA 31
ILARIS 95
ILOPROST TROMETHAMINE 108
IMATINIB MESYLATE 36
IMBRUVICA 36
IMIPENEM/CILASTATIN SODIUM 19
IMIPRAMINE HCL 26
IMIPRAMINE PAMOATE 26
IMIQUIMOD 70
IMMUNE GLOBULIN,GAMM(IGG)/GLYCINE/IGA
GREATER THAN 50 MCG/ML 95
IMMUNE
GLOBULIN,GAMM(IGG)/SORBITOL/GLYCIN/IGA 0
TO 50 MCG/ML 95
IMMUNE GLOBULIN,GAMMA (IGG)/PROLINE/IGA 0
TO 50 MCG/ML 95
IMMUNE GLOBULIN,GAMMA (IGG)/SORBITOL/IGA 0
TO 50 MCG/ML 95
IMMUNE GLOBULIN,GAMMA CAPRYLATE (IGG) 95
IMPLANON 91
INCIVEK 43
INCRELEX 83
INDAPAMIDE 61
INDINAVIR SULFATE 46
INDOCYANINE GREEN 98
INDOMETHACIN 5
INDOMETHACIN SODIUM 5
INFED 118
INFERGEN 43
INFLIXIMAB 94
INFLUENZA VIRUS VACCINE TRIVALNT 2015-2016
(4 YR & OLDER)/PF 96
INLYTA 36
INSULIN DETEMIR 50
INSULIN GLARGINE,HUMAN RECOMBINANT
ANALOG 50
INSULIN LISPRO 50
INSULIN REGULAR, HUMAN 50
INTELENCE 44
INTERFERON ALFA-2B,RECOMB. 43
INTERFERON ALFACON-1 43
INTERFERON BETA-1A 65
INTERFERON BETA-1A/ALBUMIN HUMAN 66
INTERFERON BETA-1B 66
INTERFERON GAMMA-1B,RECOMB. 95
INTRON A 43
INTROVALE 86
INVEGA SUSTENNA 41
INVEGA TRINZA 41
INVIRASE 46
INVOKAMET 48
INVOKANA 48
IPRATROPIUM BROMIDE 105
IPRATROPIUM BROMIDE/ALBUTEROL
SULFATE 109
IRBESARTAN 55
IRBESARTAN/HYDROCHLOROTHIAZIDE 59
PAGE 135 LAST UPDATED 02/2016
IRINOTECAN HCL 34
IRON ASP GLY&PS CMPLX/ASCORB.CAL/VIT
B12/FA/CA-THR/SUCC.ACID 113
IRON ASP GLY/ASCORB.CAL/VIT B12/FA/CA-
THREONTE/SUCCINIC ACID 115
IRON ASP.GLYCIN & FUMARATE /VIT C/FA/MV
COMB 11/CA-THREONATE 113
IRON ASPGLY/ASCORB.CAL/VIT B12/CALCIUM
THR/SUCC.ACID/STOMACH 115
IRON BISGLY,PSCMPLX/ASCORBATE
CALC/B12/FOLIC ACID/CALC-THREO 116
IRON CARBONYL,GLUC/FOLIC ACID/VIT B12/VIT
C/DOCUSATE SODIUM 115
IRON DEXTRAN COMPLEX 118
IRON FUMARATE & POLYSAC COMP/FOLIC
ACID/VITAMIN C/NIACIN 113
IRON FUMARATE,POLYSAC CPLEX/FOLIC
ACID/VIT B COMP WITH C #9 113
IRON FUMARATE-IRON POLYSACCHAR/FOLIC
ACID/MV COMB18 116
IRON FUMARTE &ASP GLY/ASCORB.CAL/VIT
B12/FA/CA-THR/SUCC.ACID 115
IRON HEME POLYPEPTIDE/FOLIC ACID 116
IRON POLYSACCHAR COMPLX/IRON HEME
POLYPEPTIDE/FOLIC ACID/B12 114
IRON POLYSACCHARIDE
COMPLEX/CYANOCOBALAMIN/FOLIC ACID 115
IRON,CARBONYL/ASCORBIC
ACID/CYANOCOBALAMIN/FOLIC ACID 113
IRON,CARBONYL/DOCUSATE SODIUM/B12-
IF/FOLIC ACID/MULTIVIT-MIN 116
IRON,CARBONYL/FOLIC ACID/VIT C/PYRIDOXINE
HCL/VIT B12/ZINC 112
IRON,CARBONYL/FOLIC ACID/VITAMIN
B12/VITAMIN C/DOCUSATE NA 113
IRON/FOLIC ACID/VITAMIN B COMP AND
C/MINERALS 113
ISENTRESS 44
ISOFLURANE 14
ISOMETHEPTENE
MUCATE/CAFFEINE/ACETAMINOPHEN 98
ISOMETHEPTENE
MUCATE/DICHLORALPHENAZONE/ACETAMINOPH
EN 98
ISONIAZID 30
ISOSORBIDE DINITRATE 62
ISOSORBIDE MONONITRATE 62
ISOSULFAN BLUE 98
ISOTRETINOIN 71
ISOXSUPRINE HCL 24
ISRADIPINE 57
ISTODAX 34
ITRACONAZOLE 28
IVABRADINE HCL 59
IVACAFTOR 107
IVERMECTIN 38
IXABEPILONE 34
IXEMPRA 34
IXINITY 53
JJAKAFI 36
JANTOVEN 51
JANUMET 48
JANUMET XR 48
JANUVIA 49
JENCYCLA 91
JENTADUETO 49
JINTELI 86
JOLESSA 86
JOLIVETTE 91
JUNEL 86
JUNEL FE 86
JUNEL FE 24 86
JUXTAPID 62
KK EFFERVESCENT 114
K-PHOS NEUTRAL 80
K-PHOS NO.2 80
K-PHOS ORIGINAL 114
K-SOL 114
PAGE 136 LAST UPDATED 02/2016
K-TAB ER 114
KADCYLA 37
KAITLIB FE 86
KALETRA 46
KALYDECO 107
KARIVA 86
KELNOR 1-35 86
KEPIVANCE 66
KETAMINE HCL 13
KETOCONAZOLE 28
KETOCONAZOLE/SKIN CLEANSER COMBINATION
NO.28 28
KETODAN 28
KETOPROFEN 5
KETOROLAC TROMETHAMINE 102
KIMIDESS 86
KIONEX 111
KIT FOR PREP YTTRIUM-90/IBRITUMOMAB
TIUXETAN/ALBUMIN HUMAN 38
KLOR-CON 114
KLOR-CON 10 114
KLOR-CON 8 114
KLOR-CON M10 114
KLOR-CON M15 114
KLOR-CON M20 114
KLOR-CON SPRINKLE 114
KLOR-CON-EF 114
KOATE-DVI 53
KOGENATE FS 53
KURVELO 86
KUVAN 75
LLABETALOL HCL 56
LACLOTION 70
LACOSAMIDE 24
LACTOBACILLUS COMBINATION
NO.2/S.THERMOPHL/BIF CMB NO.1 77
LACTULOSE 78
LAMISIL 28
LAMIVUDINE 45
LAMIVUDINE/ZIDOVUDINE 45
LAMOTRIGINE 23
LANSOPRAZOLE 78
LANSOPRAZOLE/AMOXICILLIN
TRIHYDRATE/CLARITHROMYCIN 77
LANTUS 50
LANTUS SOLOSTAR 50
LAPATINIB DITOSYLATE 37
LARIN 86
LARIN 24 FE 87
LARIN FE 87
LARONIDASE 74
LATANOPROST 102
LATRIX 70
LATRIX XM 70
LEDIPASVIR/SOFOSBUVIR 43
LEENA 87
LEFLUNOMIDE 96
LENALIDOMIDE 32
LESSINA 87
LETAIRIS 108
LETROZOLE 35
LEUCOVORIN CALCIUM 34
LEUKERAN 31
LEUKINE 52
LEUPROLIDE ACETATE 93
LEVALBUTEROL HCL 106
LEVEMIR 50
LEVEMIR FLEXPEN 50
LEVEMIR FLEXTOUCH 50
LEVETIRACETAM 22
LEVOBUNOLOL HCL 102
LEVOCARNITINE 118
LEVOCARNITINE (WITH SUGAR) 118
LEVOCETIRIZINE DIHYDROCHLORIDE 105
LEVOFLOXACIN 100
LEVOFLOXACIN/DEXTROSE 5 % IN WATER 21
LEVOLEUCOVORIN CALCIUM 34
LEVOMEFOLATE CALCIUM/SCHIZOCHYTRIUM
ALGAL OIL 118
LEVONEST 87
PAGE 137 LAST UPDATED 02/2016
LEVONORGESTREL 88
LEVONORGESTREL-ETHINYL ESTRADIOL 90
LEVONORGESTREL/ETHINYL ESTRADIOL AND
ETHINYL ESTRADIOL 87
LEVORA-28 87
LEVORPHANOL TARTRATE 6
LEVOTHYROXINE SODIUM 92
LEVOXYL 92
LEXIVA 46
LIDOCAINE 70
LIDOCAINE HCL 70
LIDOCAINE HCL BUFFERED WITH 8.4 % SODIUM
BICARBONATE 12
LIDOCAINE HCL/DEXTROSE 5%-WATER/PF 13
LIDOCAINE HCL/DEXTROSE 7.5%-WATER/PF 13
LIDOCAINE HCL/EPINEPHRINE 13
LIDOCAINE HCL/EPINEPHRINE/PF 13
LIDOCAINE HCL/HYDROCORTISONE ACETATE 71
LIDOCAINE HCL/MENTHOL 71
LIDOCAINE HCL/PF 13
LIDOCAINE/MENTHOL 71
LIDOCAINE/PRILOCAINE 72
LINACLOTIDE 77
LINAGLIPTIN 49
LINAGLIPTIN/METFORMIN HCL 49
LINCOMYCIN HCL 15
LINDANE 71
LINEZOLID 17
LINEZOLID IN 0.9 % SODIUM CHLORIDE 16
LINZESS 77
LIOTHYRONINE SODIUM 92
LIOTRIX 92
LIPASE/PROTEASE/AMYLASE 75
LIPODOX 34
LIPODOX 50 34
LIPOSYN III 118
LIRAGLUTIDE 49
LISDEXAMFETAMINE DIMESYLATE 63
LISINOPRIL 55
LISINOPRIL/HYDROCHLOROTHIAZIDE 59
LITHIUM CARBONATE 47
LITHIUM CITRATE 48
LMD 10% WITH 0.9% SOD CHLORIDE 98
LMD 10% WITH 5% DEXTROSE 98
LOMEDIA 24 FE 87
LOMITAPIDE MESYLATE 62
LOMUSTINE 31
LOPINAVIR/RITONAVIR 46
LOPREEZA 87
LORAZEPAM 47
LORAZEPAM INTENSOL 47
LORCET 10
LORCET HD 10
LORCET PLUS 10
LORENZA 71
LORTAB 10
LORYNA 87
LOSARTAN POTASSIUM 55
LOSARTAN
POTASSIUM/HYDROCHLOROTHIAZIDE 59
LOTRONEX 77
LOVASTATIN 62
LOW-OGESTREL 87
LOXAPINE SUCCINATE 40
LUGOL'S 98
LUMIZYME 75
LUPRON DEPOT 93
LUPRON DEPOT-PED 93
LUSTRA-ULTRA 71
LUTERA 87
LYRICA 65
LYSODREN 34
LYZA 91
MMACITENTAN 108
MAFENIDE ACETATE 71
MAG HYDROXIDE/AL
HYDROXIDE/SIMETH/DIPHENHYDRAMINE/LIDOCAI
NE 66
MAGNESIUM CHLORIDE 114
MAGNESIUM SULFATE 114
PAGE 138 LAST UPDATED 02/2016
MAGNESIUM SULFATE IN STERILE WATER 114
MAKENA 91
MALATHION 39
MANGANESE CHLORIDE 114
MANGANESE SULFATE 114
MANNITOL 60
MAPROTILINE HCL 25
MARAVIROC 45
MARGESIC 64
MARLEXATE 111
MARLISSA 87
MARQIBO 34
MARTEN-TAB 64
MATULANE 31
MATZIM LA 57
MD-GASTROVIEW 98
ME-PB-HYOS 76
MECASERMIN 83
MECHLORETHAMINE HCL 31
MECLIZINE HCL 26
MECLOFENAMATE SODIUM 5
MEDROXYPROGESTERONE ACETATE 91
MEFENAMIC ACID 5
MEFLOQUINE HCL 38
MEGESTROL ACETATE 91
MEKINIST 36
MELOXICAM 5
MELPAQUE HP 71
MELPHALAN 31
MELPHALAN HCL 31
MELQUIN HP 71
MELQUIN-3 71
MEMANTINE HCL 24
MENEST 87
MEPERIDINE HCL 10
MEPHYTON 118
MEPIVACAINE HCL 13
MEPIVACAINE HCL/PF 13
MEPRON 38
MERCAPTOPURINE 33
MEROPENEM 19
MEROPENEM IN 0.9 % SODIUM CHLORIDE 19
MESALAMINE 96
MESALAMINE WITH CLEANSING WIPES 96
MESNA 34
MESNEX 34
MESTINON 30
METADATE ER 63
METAPROTERENOL SULFATE 106
METAXALONE 110
METFORMIN HCL 64
METHADONE HCL 7
METHADONE INTENSOL 7
METHADOSE 7
METHAMPHETAMINE HCL 63
METHAZOLAMIDE 102
METHENAMINE HIPPURATE 16
METHENAMINE MANDELATE 16
METHENAMINE/METHYLENE BLUE/BENZOIC
ACID/SALICYLATE/HYOSCY 17
METHENAMINE/METHYLENE
BLUE/SALICYLATE/SODIUM PHOS/HYOSCY 17
METHENAMINE/METHYLENE BLUE/SODIUM
PHOS/PNYL SAL/HYOSC SUL 17
METHENAMINE/SODIUM
PHOSPHATE,MONOBASIC/METH BLUE/HYOSC
SUL 17
METHIMAZOLE 93
METHITEST 83
METHOCARBAMOL 110
METHOTREXATE SODIUM 95
METHOTREXATE SODIUM/PF 94
METHOXSALEN 67
METHOXSALEN, RAPID 71
METHSUXIMIDE 22
METHYCLOTHIAZIDE 61
METHYLDOPA 55
METHYLDOPA/HYDROCHLOROTHIAZIDE 59
METHYLDOPATE HCL 55
METHYLENE BLUE 98
METHYLERGONOVINE MALEATE 98
METHYLNALTREXONE BROMIDE 77
PAGE 139 LAST UPDATED 02/2016
METHYLPHENIDATE HCL 63
METHYLPREDNISOLONE 82
METHYLPREDNISOLONE ACETATE 82
METHYLPREDNISOLONE SODIUM SUCCINATE 82
METHYLTESTOSTERONE 83
METIPRANOLOL 102
METOCLOPRAMIDE HCL 26
METOLAZONE 61
METOPROLOL SUCCINATE 56
METOPROLOL TARTRATE 56
METOPROLOL
TARTRATE/HYDROCHLOROTHIAZIDE 59
METRO IV 16
METRONIDAZOLE 72
METRONIDAZOLE IN SODIUM CHLORIDE 16
METYROSINE 59
MEXILETINE HCL 56
MICAFUNGIN SODIUM 28
MICONAZOLE NITRATE 28
MICROFIBRILLAR COLLAGEN 98
MICROGESTIN 87
MICROGESTIN 24 FE 87
MICROGESTIN FE 87
MIDAZOLAM HCL 47
MIDAZOLAM HCL/PF 47
MIDODRINE HCL 55
MIGERGOT 29
MIGLUSTAT 75
MIGRAGESIC IDA 98
MILLIPRED DP 82
MILNACIPRAN HCL 65
MILRINONE LACTATE 59
MILRINONE LACTATE/DEXTROSE 5 % IN WATER59
MIMVEY 87
MIMVEY LO 88
MINOCYCLINE HCL 21
MINOXIDIL 62
MIOSTAT 102
MIRTAZAPINE 25
MISOPROSTOL 78
MITOMYCIN 34
MITOTANE 34
MITOXANTRONE HCL 34
MODAFINIL 111
MODERIBA 43
MOEXIPRIL HCL 55
MOEXIPRIL HCL/HYDROCHLOROTHIAZIDE 60
MOLINDONE HCL 40
MOLYBDENUM (AMMONIUM MOLYBDATE) 114
MOMETASONE FUROATE 71
MOMETASONE FUROATE/FORMOTEROL
FUMARATE 109
MONDOXYNE NL 21
MONO-LINYAH 88
MONOJECT 0.9% SODIUM CHLORIDE 114
MONOJECT PREFILL 115
MONOJECT PREFILL ADVANCED 115
MONONESSA 88
MONONINE 53
MONSEL'S 53
MONTELUKAST SODIUM 105
MORPHINE SULFATE 11
MORPHINE SULFATE/PF 11
MOXEZA 100
MOXIFLOXACIN HCL 100
MOXIFLOXACIN HCL IN SODIUM ACETATE AND
SULFATE,WATER,ISO-OSM 21
MOXIFLOXACIN HCL/SODIUM CHLORIDE, ISO-
OSMOTIC 20
MOZOBIL 52
MULTIGEN 115
MULTIGEN FOLIC 115
MULTIGEN PLUS 115
MULTITRACE-4 115
MULTITRACE-5 115
MULTIVITAMINS WITH MIN NO.7/FOLIC ACID 119
MUPIROCIN 71
MUPIROCIN CALCIUM 71
MUSTARGEN 31
MY WAY 88
MYCAMINE 28
MYCOBUTIN 30
PAGE 140 LAST UPDATED 02/2016
MYCOPHENOLATE MOFETIL 94
MYCOPHENOLATE MOFETIL HCL 93
MYCOPHENOLATE SODIUM 94
MYFORTIC 94
MYLERAN 31
MYNATAL PLUS 118
MYNATAL-Z 118
MYNEPHROCAPS 118
MYORISAN 71
MYOZYME 75
MYZILRA 88
NNABUMETONE 5
NADOLOL 57
NADOLOL/BENDROFLUMETHIAZIDE 60
NAFCILLIN IN DEXTROSE, ISO-OSMOTIC 19
NAFCILLIN SODIUM 19
NAGLAZYME 75
NALBUPHINE HCL 11
NALOXONE HCL 14
NALTREXONE HCL 14
NAMENDA 24
NAPHAZOLINE HCL 100
NAPROXEN 5
NAPROXEN SODIUM 5
NARATRIPTAN HCL 29
NAROPIN 13
NATACYN 28
NATALVIRT FLT 115
NATAMYCIN 28
NATEGLINIDE 49
NATURE-THROID 92
NEBUPENT 38
NECON 88
NELARABINE 33
NELFINAVIR MESYLATE 46
NEO-POLYCIN 100
NEO-POLYCIN HC 100
NEOMYCIN SULFATE 15
NEOMYCIN SULFATE/BACITRACIN
ZINC/POLYMYXIN B/HYDROCORTISONE 100
NEOMYCIN SULFATE/BACITRACIN/POLYMYXIN
B 101
NEOMYCIN SULFATE/POLYMYXIN B SULFATE 16
NEOMYCIN SULFATE/POLYMYXIN B
SULFATE/GRAMICIDIN D 101
NEOMYCIN SULFATE/POLYMYXIN B
SULFATE/HYDROCORTISONE 103
NEOMYCIN/POLYMYXIN B
SULFATE/DEXAMETHASONE 101
NEOSTIGMINE BROMIDE 30
NEOSTIGMINE METHYLSULFATE 30
NEPHPLEX RX 118
NEPHRO-VITE RX 118
NEUAC 71
NEULASTA 52
NEUMEGA 52
NEVIRAPINE 45
NEXAVAR 36
NEXT CHOICE ONE DOSE 88
NIACIN 62
NICARDIPINE HCL 57
NICARDIPINE HCL IN 0.9 % SODIUM CHLORIDE 57
NIFEDIAC CC 57
NIFEDICAL XL 57
NIFEDIPINE 57
NIKKI 88
NILANDRON 32
NILOTINIB HCL 37
NILUTAMIDE 32
NIMODIPINE 58
NISOLDIPINE 58
NITAZOXANIDE 38
NITISINONE 75
NITRO-BID 62
NITRO-TIME 62
NITROFURANTOIN 16
NITROFURANTOIN MACROCRYSTAL 16
NITROFURANTOIN
MONOHYDRATE/MACROCRYSTALS 16
PAGE 141 LAST UPDATED 02/2016
NITROGLYCERIN 72
NITROGLYCERIN/DEXTROSE 5 % IN WATER 63
NITROSTAT 63
NIVA-PLUS 118
NIZATIDINE 77
NODOLOR 98
NORA-BE 91
NORDITROPIN 83
NORDITROPIN FLEXPRO 83
NORDITROPIN NORDIFLEX 83
NOREPINEPHRINE BITARTRATE 60
NOREPINEPHRINE BITARTRATE IN 0.9 % SODIUM
CHLORIDE 60
NORETHINDRONE 91
NORETHINDRONE ACETATE 91
NORETHINDRONE ACETATE-ETHINYL
ESTRADIOL 88
NORETHINDRONE ACETATE-ETHINYL
ESTRADIOL/FERROUS FUMARATE 89
NORETHINDRONE-ETHINYL ESTRADIOL 90
NORETHINDRONE-ETHINYL
ESTRADIOL/FERROUS FUMARATE 90
NORGESTIMATE-ETHINYL ESTRADIOL 89
NORGESTREL-ETHINYL ESTRADIOL 88
NORLYROC 91
NORTHERA 60
NORTREL 88
NORTRIPTYLINE HCL 26
NORVIR 46
NOVAREL 83
NOVOEIGHT 53
NOVOSEVEN RT 53
NOXAFIL 28
NP THYROID 92
NU-DERM 71
NUEDEXTA 64
NULOJIX 94
NUQUIN HP 71
NUTRILIPID 118
NUTRILYTE 115
NUTRILYTE II 115
NYAMYC 28
NYSTATIN 28
NYSTATIN/LIDOCAINE HCL/DIPHENHYDRAMINE
HCL 27
NYSTATIN/TRIAMCINOLONE ACETONIDE 28
NYSTOP 28
OOCELLA 88
OCTREOTIDE ACETATE 93
OCUCOAT 101
OCUDOX 21
OFATUMUMAB 37
OFLOXACIN 103
OGEN 88
OGESTREL 88
OLANZAPINE 42
OLANZAPINE/FLUOXETINE HCL 25
OLODATEROL HCL 106
OLOPATADINE HCL 105
OMALIZUMAB 110
OMBITASVIR/PARITAPREVIR/RITONAVIR 44
OMBITASVIR/PARITAPREVIR/RITONAVIR/DASABU
VIR SODIUM 44
OMEGA-3 ACID ETHYL ESTERS 62
OMEPRAZOLE 79
OMEPRAZOLE/SODIUM BICARBONATE 79
ONDANSETRON 27
ONDANSETRON HCL 27
ONDANSETRON HCL/PF 27
ONFI 22
ONXOL 35
OPIUM TINCTURE 77
OPIUM/BELLADONNA ALKALOIDS 11
OPRELVEKIN 52
OPSUMIT 108
ORFADIN 75
ORPHENADRINE CITRATE 110
ORPHENADRINE CITRATE/ASPIRIN/CAFFEINE 110
ORSYTHIA 88
OSCIMIN 76
PAGE 142 LAST UPDATED 02/2016
OSCIMIN SL 76
OSCIMIN SR 76
OSELTAMIVIR PHOSPHATE 46
OSMITROL 60
OTICIN HC 103
OTO-END 10 103
OTOMAX-HC 103
OTOZIN 103
OXACILLIN SODIUM 19
OXACILLIN SODIUM/DEXTROSE, ISO-OSMOTIC 19
OXALIPLATIN 35
OXANDROLONE 83
OXAPROZIN 6
OXAZEPAM 47
OXCARBAZEPINE 23
OXSORALEN-ULTRA 71
OXYBENZONE/OCTINOXATE/HYDROQUINONE 67
OXYBUTYNIN CHLORIDE 79
OXYCODONE HCL 11
OXYCODONE HCL/ACETAMINOPHEN 12
OXYCODONE HCL/ASPIRIN 11
OXYCONTIN 8
OXYMORPHONE HCL 12
OXYTOCIN 99
PPACERONE 56
PACLITAXEL 35
PACLITAXEL PROTEIN-BOUND 33
PAIN RELIEF 71
PALBOCICLIB 36
PALGIC 105
PALIFERMIN 66
PALIPERIDONE 42
PALIPERIDONE PALMITATE 41
PALIVIZUMAB 96
PANCURONIUM BROMIDE 64
PANHEMATIN 99
PANITUMUMAB 38
PANTOPRAZOLE SODIUM 79
PAPAVERINE HCL 24
PAREGORIC 77
PARENTERAL AMINO ACID 10% COMBINATION
NO. 4 117
PARENTERAL AMINO ACID 10% COMBINATION
NO. 6 119
PARENTERAL AMINO ACID 10% COMBINATION
NO.7 118
PARENTERAL AMINO ACID 15% COMBINATION
NO.1 117
PARICALCITOL 97
PAROEX 66
PAROMOMYCIN SULFATE 15
PAROXETINE HCL 25
PASIREOTIDE DIASPARTATE 93
PAZOPANIB HCL 37
PEDI-DRI 28
PEDIATRIC MULTIVITAMIN COMBO
NO.75/FLUORIDE/FERROUS SULFATE 118
PEGANONE 23
PEGASYS 43
PEGASYS PROCLICK 43
PEGFILGRASTIM 52
PEGINTERFERON ALFA-2A 43
PEGINTERFERON ALFA-2B 35
PEMETREXED DISODIUM 32
PENICILLAMINE 80
PENICILLIN G POTASSIUM 20
PENICILLIN G PROCAINE 19
PENICILLIN G SODIUM 19
PENICILLIN V POTASSIUM 19
PENTAMIDINE ISETHIONATE 38
PENTASA 96
PENTAZOCINE HCL/NALOXONE HCL 12
PENTOSAN POLYSULFATE SODIUM 80
PENTOSTATIN 33
PENTOXIFYLLINE 60
PERFOROMIST 106
PERINDOPRIL ERBUMINE 55
PERIOGARD 66
PERITONEAL DIALYSIS NO.6 WITH DEXTROSE 1.5
% 112
PAGE 143 LAST UPDATED 02/2016
PERITONEAL DIALYSIS NO.7 WITH DEXTROSE 2.5
% 112
PERITONEAL DIALYSIS NO.8 WITH DEXTROSE
4.25 % 112
PERJETA 38
PERMETHRIN 72
PERPHENAZINE 26
PERPHENAZINE/AMITRIPTYLINE HCL 25
PERTUZUMAB 38
PFIZERPEN 20
PHENADOZ 105
PHENAZOPYRIDINE HCL 80
PHENDIMETRAZINE TARTRATE 64
PHENELZINE SULFATE 25
PHENERGAN 105
PHENOBARBITAL 22
PHENOBARBITAL SODIUM 22
PHENOBARBITAL/HYOSCYAMINE SULF/ATROPINE
SULF/SCOPOLAMINE HB 76
PHENOL 99
PHENOXYBENZAMINE HCL 55
PHENTERMINE HCL 64
PHENTOLAMINE MESYLATE 55
PHENYLEPHRINE HCL 101
PHENYLEPHRINE HCL IN 0.9 % SODIUM
CHLORIDE 60
PHENYLEPHRINE HCL IN 0.9 % SODIUM
CHLORIDE/PF 60
PHENYLEPHRINE HCL/PROMETHAZINE HCL 109
PHENYTOIN 23
PHENYTOIN SODIUM 23
PHENYTOIN SODIUM EXTENDED 23
PHILITH 88
PHOSPHA 250 NEUTRAL 80
PHOSPHASAL 16
PHOSPHOLINE IODIDE 102
PHOSPHORUS #1 81
PHOTOFRIN 35
PHYSOSTIGMINE SALICYLATE 99
PHYTONADIONE 118
PILOCARPINE HCL 102
PIMOZIDE 40
PIMTREA 88
PINDOLOL 57
PIOGLITAZONE HCL 49
PIOGLITAZONE HCL/GLIMEPIRIDE 49
PIOGLITAZONE HCL/METFORMIN HCL 49
PIPERACILLIN SODIUM/TAZOBACTAM SODIUM 20
PIRMELLA 88
PIROXICAM 6
PLERIXAFOR 52
PNEUMOCOCCAL 23-VALENT POLYSACCHARIDE
VACCINE 96
PNEUMOVAX 23 96
PNV 29-1 118
PNV-SELECT 118
PNV-VP-U 118
PODOFILOX 72
POLOCAINE 13
POLOCAINE-MPF 13
POLYCIN 101
POLYETHYLENE GLYCOL 3350 78
POLYMYXIN B SULFATE 16
POLYMYXIN B SULFATE/TRIMETHOPRIM 101
POLYSACCHARIDE IRON FORTE 115
POMALIDOMIDE 32
POMALYST 32
PONATINIB HCL 36
PORFIMER SODIUM 35
PORTIA 89
POSACONAZOLE 28
POTASSIUM ACETATE 115
POTASSIUM BICARBONATE/CITRIC ACID 115
POTASSIUM CHLORIDE 115
POTASSIUM CHLORIDE IN 0.45 % SODIUM
CHLORIDE 116
POTASSIUM CHLORIDE IN 0.9 % SODIUM
CHLORIDE 115
POTASSIUM CHLORIDE IN 5 % DEXTROSE IN
WATER 115
POTASSIUM CHLORIDE IN DEXTROSE 5 % AND 0.9
% SODIUM CHLORIDE 115
PAGE 144 LAST UPDATED 02/2016
POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.2 %
SODIUM CHLORIDE 116
POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.45 %
SODIUM CHLORIDE 116
POTASSIUM CHLORIDE IN DEXTROSE 5% AND 0.3
% SODIUM CHLORIDE 116
POTASSIUM CHLORIDE IN LACTATED RINGERS
AND 5 % DEXTROSE 116
POTASSIUM CHLORIDE/POTASSIUM
BICARBONATE/CITRIC ACID 115
POTASSIUM CITRATE 80
POTASSIUM CITRATE/CITRIC ACID 81
POTASSIUM IODIDE/IODINE 99
POTASSIUM PHOS,M-BASIC-D-BASIC 116
POTASSIUM PHOSPHATE IN 0.9 % SODIUM
CHLORIDE 116
POTASSIUM PHOSPHATE,MONOBASIC 114
POTIGA 22
PR BENZOYL PEROXIDE 72
PR CREAM 72
PRADAXA 51
PRALATREXATE 33
PRALIDOXIME CHLORIDE 99
PRAMCORT 72
PRAMIPEXOLE DI-HCL 39
PRAMLINTIDE ACETATE 49
PRAMOXINE-HC 103
PRASUGREL HCL 54
PRAVASTATIN SODIUM 62
PRAZOSIN HCL 55
PRE-ATTACHED LTA KIT 67
PRED MILD 102
PREDNICARBATE 72
PREDNISOLONE 82
PREDNISOLONE ACETATE 102
PREDNISOLONE SOD PHOSPHATE 102
PREDNISONE 82
PREDNISONE INTENSOL 82
PREGABALIN 65
PREMASOL 118
PREMPHASE 89
PREMPRO 89
PRENA1 CHEW 118
PRENAPLUS 119
PRENATAL VIT WITH CALCIUM CMB 11/FERROUS
FUMARATE/FOLIC ACID 120
PRENATAL VIT WITH CALCIUM NO. 40/IRON
FUMARATE/FA CMB NO.1 119
PRENATAL VIT WITH CALCIUM NO.66/IRON
FUM/FOLIC ACID/DSS/DHA 120
PRENATAL VITAMIN COMBO NO.8/IRON PS CMPLX
& ASPGL/FA/DHA 119
PRENATAL VITAMIN
NO.15/IRON,CARBONYL/FOLIC ACID/DOCUSATE
SOD 119
PRENATAL VITAMIN
NO.16/IRON,CARBONYL/FOLIC ACID/DOCUSATE
SOD 120
PRENATAL VITAMIN NO.81/SODIUM FEREDETATE-
IRON POLY/FA/OMEGA3 119
PRENATAL VITAMINS COMB 10/FERROUS
FUMARATE/FOLIC ACID 120
PRENATAL VITAMINS COMBINATION NO.42/FOLIC
ACID 118
PRENATAL VITAMINS NO.11/FERROUS
FUMARATE/FOLIC ACID/OMEGA-3 119
PRENATAL VITAMINS WITH CALCIUM/FERROUS
FUMARATE/FOLIC ACID 118
PRENATAL VITS WITH CALCIUM #72/FERROUS
FUMARATE/FOLIC ACID 118
PRENATAL VITS WITH CALCIUM #73/FERROUS
FUMARATE/FOLIC ACID 119
PRENATAL VITS WITH CALCIUM #74/FERROUS
FUMARATE/FOLIC ACID 120
PRENATAL VITS WITH CALCIUM
#76/IRON,CARBONYL/FOLIC ACID 119
PRENATAL VITS WITH CALCIUM #78/FERROUS
FUMARATE/FOLIC ACID 119
PRENATAL VITS WITHOUT CALC NO5/FERROUS
FUMARATE/FOLIC ACID 118
PRETAB 119
PREVALITE 62
PAGE 145 LAST UPDATED 02/2016
PREVIFEM 89
PREZISTA 46
PRIFTIN 30
PRIMIDONE 22
PRIVIGEN 95
PROBENECID 29
PROCAINAMIDE HCL 56
PROCARBAZINE HCL 31
PROCENTRA 63
PROCHLORPERAZINE 26
PROCHLORPERAZINE EDISYLATE 26
PROCHLORPERAZINE MALEATE 26
PROCRIT 52
PROCTO-PAK 96
PROCTOSOL-HC 97
PROCTOZONE-HC 97
PROFERRIN-FORTE 116
PROFILNINE 53
PROFILNINE SD 54
PROGESTERONE 91
PROGESTERONE,MICRONIZED 91
PROGLYCEM 50
PROGRAF 94
PROLASTIN 109
PROLASTIN C 109
PROMACTA 52
PROMETHAZINE HCL 105
PROMETHAZINE HCL/CODEINE 109
PROMETHAZINE HCL/DEXTROMETHORPHAN
HBR 109
PROMETHEGAN 105
PROPAFENONE HCL 56
PROPARACAINE HCL 101
PROPARACAINE HCL/FLUORESCEIN SODIUM 101
PROPOFOL 13
PROPRANOLOL HCL 57
PROPRANOLOL HCL/HYDROCHLOROTHIAZIDE 60
PROPYLTHIOURACIL 93
PROSTIGMIN 30
PROTAMINE SULFATE 51
PROTECTIVES COMBINATION NO.2/CERAMIDES
1,3,6-11 72
PROTOPAM CHLORIDE 99
PROTRIPTYLINE HCL 26
PULMICORT FLEXHALER 104
PULMOZYME 109
PUREVIT DUALFE PLUS 116
PURINETHOL 33
PYRAZINAMIDE 30
PYRIDOSTIGMINE BROMIDE 30
PYRIMETHAMINE 38
QQUASENSE 89
QUAZEPAM 110
QUETIAPINE FUMARATE 42
QUINAPRIL HCL 55
QUINAPRIL HCL/HYDROCHLOROTHIAZIDE 60
QUINIDINE GLUCONATE 56
QUINIDINE SULFATE 56
QUININE SULFATE 39
QVAR 104
RRABEPRAZOLE SODIUM 79
RADIOPAQUE PVC MARKERS/BARIUM SULFATE 99
RALOXIFENE HCL 91
RALTEGRAVIR POTASSIUM 44
RAMELTEON 111
RAMIPRIL 55
RANITIDINE HCL 77
RAPAMUNE 94
RASBURICASE 33
RAVICTI 75
REA LO 39 72
REA LO 40 72
REBIF 66
REBIF REBIDOSE 66
RECLIPSEN 89
RECOMBINATE 54
RECTACORT-HC 82
PAGE 146 LAST UPDATED 02/2016
RECTIV 72
REGONOL 30
REGORAFENIB 36
REGRANEX 72
RELADOR PAK 72
RELADOR PAK PLUS 72
RELENZA 46
RELISTOR 77
REMEVEN 72
REMICADE 94
REMODULIN 108
RENA-VITE RX 119
RENACIDIN 80
RENAL CAPS 119
RENO CAPS 119
RENVELA 81
REPAGLINIDE 49
REPAGLINIDE/METFORMIN HCL 49
REPREXAIN 12
RESCRIPTOR 44
RESERPINE 55
RESTASIS 101
REVATIO 108
REVLIMID 32
REVONTO 110
REYATAZ 46
RHO(D) IMMUNE GLOBULIN 95
RIASTAP 54
RIBASPHERE 43
RIBASPHERE RIBAPAK 43
RIBAVIRIN 44
RIDAURA 96
RIFABUTIN 30
RIFAMPIN 30
RIFAPENTINE 30
RIFAXIMIN 17
RILONACEPT 95
RILPIVIRINE HCL 44
RILUZOLE 64
RIMANTADINE HCL 46
RINGERS SOLUTION 119
RINGERS SOLUTION,LACTATED 119
RIOCIGUAT 108
RIOMET 49
RISEDRONATE SODIUM 97
RISPERDAL CONSTA 42
RISPERIDONE 42
RISPERIDONE MICROSPHERES 42
RITONAVIR 46
RITUXAN 38
RITUXIMAB 38
RIVAROXABAN 51
RIVASTIGMINE 24
RIVASTIGMINE TARTRATE 24
RIZATRIPTAN BENZOATE 29
ROCURONIUM BROMIDE 64
ROMIDEPSIN 34
ROPINIROLE HCL 39
ROPIVACAINE HCL/PF 13
ROSADAN 72
ROSULA 72
ROXICET 12
ROZEREM 111
RUFINAMIDE 23
RUXOLITINIB PHOSPHATE 36
SSABRIL 22
SACROSIDASE 75
SALACYN 72
SALICYLIC ACID 72
SALICYLIC ACID/AMMONIUM LACTATE/ALOE
VERA 72
SALICYLIC ACID/CERAMIDES 1,3,6-11 72
SALSALATE 6
SALVAX 72
SAMSCA 111
SANTYL 72
SAPROPTERIN DIHYDROCHLORIDE 75
SAQUINAVIR MESYLATE 46
SARGRAMOSTIM 52
SAVELLA 65
PAGE 147 LAST UPDATED 02/2016
SCALACORT 73
SE 10-5 SS 73
SE BPO 73
SE-TAN PLUS 116
SEB-PREV 73
SECOBARBITAL SODIUM 111
SECONAL SODIUM 111
SELEGILINE HCL 40
SELENIUM 116
SELENIUM SULFIDE 73
SELZENTRY 45
SENSIPAR 92
SENSORCAINE 13
SENSORCAINE-EPINEPHRINE 13
SENSORCAINE-MPF 13
SEROQUEL XR 42
SERTRALINE HCL 25
SETLAKIN 89
SEVELAMER CARBONATE 81
SEVOFLURANE 14
SHAROBEL 91
SIGNIFOR 93
SILDENAFIL CITRATE 108
SILVER NITRATE 73
SILVER NITRATE/POTASSIUM NITRATE 73
SILVER SULFADIAZINE 74
SIMVASTATIN 62
SIROLIMUS 94
SIRTURO 30
SITAGLIPTIN PHOSPHATE 49
SITAGLIPTIN PHOSPHATE/METFORMIN HCL 48
SITZMARKS 99
SODIUM ACETATE 116
SODIUM BICARBONATE 116
SODIUM CHLORIDE 0.45 % 116
SODIUM CHLORIDE 3 % 116
SODIUM CHLORIDE 5 % 116
SODIUM CHLORIDE FOR INHALATION 109
SODIUM CHLORIDE IRRIGATING SOLUTION 80
SODIUM CHLORIDE IRRIGATING
SOLUTION/HYPOCHLOROUS ACID 74
SODIUM CITRATE DIHYDRATE 51
SODIUM FLUORIDE 119
SODIUM FLUORIDE/XYLITOL 117
SODIUM LACTATE 116
SODIUM MORRHUATE 99
SODIUM OXYBATE 111
SODIUM PHENYLBUTYRATE 75
SODIUM PHOS,M-BASIC-D-BASIC 116
SODIUM PHOSPHATE,MONOBASIC/POTASSIUM
PHOSPHATE,MONOBASIC 80
SODIUM POLYSTYRENE SULFONATE 112
SODIUM TETRADECYL SULFATE 99
SODIUM THIOSULFATE 99
SODIUM/POTASSIUM/MAGNES/CALCIUM/CHLORID
E/ACETATE/GLUCONATE 115
SODIUM/POTASSIUM/MAGNESIUM/CALCIUM/CHLO
RIDE/ACETATE 115
SODIUM/POTASSIUM/POTASSIUM
CITRATE/SODIUM CITRATE/CIT AC 81
SOFOSBUVIR 44
SOJOURN 14
SOLIRIS 99
SOMATROPIN 83
SORAFENIB TOSYLATE 36
SORINE 56
SOTALOL HCL 56
SOTRADECOL 99
SOVALDI 44
SPINOSAD 73
SPIRIVA 105
SPIRIVA RESPIMAT 105
SPIRONOLACTONE 61
SPIRONOLACTONE/HYDROCHLOROTHIAZIDE 60
SPORANOX 28
SPRINTEC 89
SPRYCEL 36
SPS 112
SRONYX 89
SS 10-2 73
SSD 73
SSS 10-5 73
PAGE 148 LAST UPDATED 02/2016
STAVUDINE 45
STIMATE 83
STIOLTO RESPIMAT 110
STIVARGA 36
STRATTERA 64
STRENSIQ 75
STREPTOZOCIN 32
STRIBILD 44
STRIVERDI RESPIMAT 106
STROMECTOL 38
SUBLIMAZE 12
SUBOXONE 14
SUCCIMER 111
SUCCINYLCHOLINE CHLORIDE 110
SUCRAID 75
SUCRALFATE 78
SUFENTA 12
SUFENTANIL CITRATE 12
SULFACETAMIDE SODIUM 101
SULFACETAMIDE SODIUM/PREDNISOLONE
SODIUM PHOSPHATE 101
SULFACETAMIDE SODIUM/SULFUR 74
SULFACETAMIDE SODIUM/SULFUR/SKIN
CLEANSER COMB NO.23 73
SULFACETAMIDE SODIUM/SULFUR/UREA 73
SULFACETAMIDE SODIUM/SULFUR/WITCH
HAZEL 73
SULFACLEANSE 8-4 73
SULFADIAZINE 21
SULFAMETHOXAZOLE/TRIMETHOPRIM 21
SULFAMYLON 16
SULFASALAZINE 97
SULFATRIM 21
SULFAZINE 97
SULFAZINE EC 97
SULFURIC ACID/SULFONATED PHENOL 66
SULINDAC 6
SUMATRIPTAN 29
SUMATRIPTAN SUCCINATE 29
SUNITINIB MALATE 37
SUSTIVA 45
SUTENT 37
SYEDA 89
SYLATRON 35
SYLATRON 4-PACK 35
SYMAX 76
SYMAX-SL 76
SYMAX-SR 76
SYMBICORT 110
SYMLINPEN 120 49
SYMLINPEN 60 49
SYNAGIS 96
SYREX 116
TTABLOID 33
TACROLIMUS 94
TADALAFIL 108
TAFINLAR 37
TALIGLUCERASE ALFA 75
TAMIFLU 46
TAMOXIFEN CITRATE 32
TAMSULOSIN HCL 79
TARCEVA 37
TARGRETIN 38
TARINA FE 89
TARON FORTE 116
TARON-CRYSTALS 80
TASIGNA 37
TASIMELTEON 111
TASMAR 39
TAZAROTENE 74
TAZORAC 74
TAZTIA XT 58
TECFIDERA 66
TECHNIVIE 44
TEGRETOL XR 23
TELAPREVIR 43
TELBIVUDINE 43
TELMISARTAN 55
TELMISARTAN/AMLODIPINE BESYLATE 60
TELMISARTAN/HYDROCHLOROTHIAZIDE 60
PAGE 149 LAST UPDATED 02/2016
TEMAZEPAM 111
TEMODAR 31
TEMOZOLOMIDE 31
TEMSIROLIMUS 37
TENCON 65
TENIPOSIDE 35
TENOFOVIR DISOPROXIL FUMARATE 45
TERAZOSIN HCL 79
TERBINAFINE HCL 28
TERBUTALINE SULFATE 106
TERCONAZOLE 29
TERIPARATIDE 97
TERRELL 14
TESAMORELIN ACETATE 93
TESTOPEL 83
TESTOSTERONE 84
TESTOSTERONE CYPIONATE 84
TESTOSTERONE ENANTHATE 84
TETCAINE 101
TETRABENAZINE 65
TETRACAINE HCL 101
TETRACAINE HCL/PF 101
TETRACYCLINE HCL 21
THALIDOMIDE 32
THALOMID 32
THEOCHRON 107
THEOPHYLLINE ANHYDROUS 107
THEOPHYLLINE/DEXTROSE 5 % IN WATER 108
THERACYS 35
THERAPEUTIC VITAMIN W-MINERALS 119
THERMAZENE 74
THIAMINE HCL 119
THIOGUANINE 33
THIORIDAZINE HCL 40
THIOTEPA 35
THIOTHIXENE 40
THRIVITE RX 119
THYROID,PORK 92
THYROLAR-1 92
THYROLAR-1/2 92
THYROLAR-1/4 92
THYROLAR-2 92
THYROLAR-3 92
TIAGABINE HCL 22
TICAGRELOR 54
TIGECYCLINE 16
TIKOSYN 56
TIMOLOL MALEATE 102
TINIDAZOLE 16
TIOTROPIUM BROMIDE 105
TIOTROPIUM BROMIDE/OLODATEROL HCL 110
TIPRANAVIR 45
TIVICAY 44
TIZANIDINE HCL 110
TL G-FOL OS 119
TL ICON 116
TL-HEM 150 116
TOBI 107
TOBI PODHALER 107
TOBRAMYCIN 107
TOBRAMYCIN IN 0.225 % SODIUM CHLORIDE 107
TOBRAMYCIN SULFATE 15
TOBRAMYCIN SULFATE/SODIUM CHLORIDE 15
TOBRAMYCIN/DEXAMETHASONE 101
TOBRAMYCIN/NEBULIZER 107
TOCILIZUMAB 95
TOLAZAMIDE 49
TOLBUTAMIDE 49
TOLCAPONE 39
TOLMETIN SODIUM 6
TOLTERODINE TARTRATE 79
TOLVAPTAN 111
TOPIRAGEN 23
TOPIRAMATE 23
TOPOSAR 35
TOREMIFENE CITRATE 32
TORISEL 37
TORSEMIDE 61
TOSITUMOMAB (WITH MALTOSE) 37
TRACLEER 108
TRADJENTA 49
TRAMADOL HCL 12
PAGE 150 LAST UPDATED 02/2016
TRAMADOL HCL/ACETAMINOPHEN 12
TRAMETINIB DIMETHYL SULFOXIDE 36
TRANDOLAPRIL 55
TRANDOLAPRIL/VERAPAMIL HCL 60
TRANEXAMIC ACID 54
TRANYLCYPROMINE SULFATE 25
TRASTUZUMAB 37
TRAVASOL 119
TRAVOPROST (BENZALKONIUM) 102
TRAZODONE HCL 25
TREANDA 31
TREPROSTINIL SODIUM 108
TREPROSTINIL/NEBULIZER/NEBULIZER
ACCESSORIES 108
TRETINOIN 74
TRETINOIN MICROSPHERES 74
TRETTEN 54
TREXALL 95
TRI-CHLOR 74
TRI-ESTARYLLA 89
TRI-LEGEST FE 89
TRI-LINYAH 89
TRI-LO-ESTARYLLA 89
TRI-LO-MARZIA 89
TRI-LO-SPRINTEC 89
TRI-PREVIFEM 89
TRI-SPRINTEC 89
TRIACETIN 29
TRIAMCINOLONE ACETONIDE 104
TRIAMTERENE/HYDROCHLOROTHIAZIDE 60
TRIANEX 74
TRIAZOLAM 111
TRICHLOROACETIC ACID 74
TRICITRASOL 51
TRICITRATES 80
TRICON 117
TRIDERM 74
TRIFLUOPERAZINE HCL 40
TRIFLURIDINE 46
TRIGELS-F FORTE 117
TRIHEXYPHENIDYL HCL 39
TRIMETHOBENZAMIDE HCL 26
TRIMETHOPRIM 16
TRINESSA 89
TRISENOX 35
TRIVORA-28 90
TROPICAMIDE 101
TROSPIUM CHLORIDE 79
TRUVADA 45
TRYPSIN/BALSAM PERU/CASTOR OIL 74
TUDORZA PRESSAIR 106
TUSSIGON 110
TYGACIL 16
TYKERB 37
TYVASO 108
TYZEKA 43
UUCERIS 97
ULORIC 29
ULTIMATE OB DHA 119
UMECTA 74
UNITHROID 92
UR N-C 16
UREA 74
UREA/HYALURONATE SODIUM 74
UREA/LACTIC ACID/SALICYLIC ACID 74
UREA/LACTIC ACID/ZINC UNDECYLENATE 74
URETRON D-S 16
URIMAR-T 16
URIN D.S. 16
URO-BLUE 16
UROGESIC-BLUE 17
UROLET MB 17
UROPHEN MB 17
URSODIOL 77
URYL 17
USTELL 17
UTIRA-C 17
VVAGIFEM 90
PAGE 151 LAST UPDATED 02/2016
VALACYCLOVIR HCL 46
VALCHLOR 31
VALCYTE 43
VALGANCICLOVIR HCL 43
VALPROIC ACID 23
VALPROIC ACID (AS SODIUM SALT) (VALPROATE
SODIUM) 22
VALSARTAN 55
VALSARTAN/HYDROCHLOROTHIAZIDE 60
VANCOMYCIN HCL 17
VANCOMYCIN HCL/DEXTROSE 5 % IN WATER 17
VANCOMYCIN IN 0.9 % SODIUM CHLORIDE 17
VANCOMYCIN IN DEXTROSE, ISO-OSMOTIC 17
VANDAZOLE 17
VANDETANIB 36
VANTAS 93
VARENICLINE TARTRATE 14
VARICELLA-ZOSTER IMMUNE GLOBULIN
(HUMAN) 95
VARIZIG 95
VASCEPA 62
VASHE WOUND THERAPY 74
VASOLEX 74
VASOPRESSIN 83
VECTIBIX 38
VECURONIUM BROMIDE 65
VELAGLUCERASE ALFA 75
VELETRI 108
VELIVET 90
VEMURAFENIB 37
VENA-BAL DHA 119
VENLAFAXINE HCL 25
VENTAVIS 108
VENTOLIN HFA 106
VERAPAMIL HCL 58
VERDROCET 12
VERIPRED 20 82
VESTURA 90
VICODIN 12
VICODIN ES 12
VICODIN HP 12
VICTOZA 2-PAK 49
VICTOZA 3-PAK 49
VICTRELIS 44
VIDEX 45
VIEKIRA PAK 44
VIENVA 90
VIGABATRIN 22
VIMPAT 24
VINBLASTINE SULFATE 35
VINCASAR PFS 35
VINCRISTINE SULFATE 35
VINCRISTINE SULFATE LIPOSOMAL 34
VINORELBINE TARTRATE 35
VIORELE 90
VIRACEPT 46
VIRAMUNE XR 45
VIREAD 45
VIRT NATE 119
VIRT-ADVANCE 119
VIRT-CAPS 119
VIRT-NATE 119
VIRT-NATE DHA 119
VIRT-PHOS 250 NEUTRAL 81
VIRT-PN 119
VIRT-VITE GT 120
VIRTI-SULF 74
VIRTPREX 120
VIRTRATE-2 81
VIRTRATE-3 81
VIRTRATE-K 81
VISMODEGIB 36
VITAFOL-OB 120
VITAFOL-PN 120
VITAMIN A/VITAMIN
E/AVOBENZONE/OCTINOXATE/HYDROQUINONE 71
VITAMIN B COMPLEX & VITAMIN C NO.20/FOLIC
ACID 119
VITAMIN B COMPLX NO.3/FOLIC ACID/ASCORBIC
ACID/BIOTIN 120
VITAMIN B COMPLX NO.3/FOLIC ACID/ASCORBIC
ACID/BIOTIN/ZNOX 118
PAGE 152 LAST UPDATED 02/2016
VOL-CARE RX 120
VOL-PLUS 120
VORAPAXAR SULFATE 54
VORICONAZOLE 29
VORINOSTAT 35
VOTRIENT 37
VP-VITE RX 120
VPRIV 75
VSL#3 DS 77
VUMON 35
VYFEMLA 90
VYVANSE 63
WWARFARIN SODIUM 51
WATER FOR INJ.,BACTERIOSTATIC 99
WATER FOR
INJ.,BACTERIOSTATIC/METHYLPARABEN/PROPYL
PARABEN 99
WATER FOR INJECTION,STERILE 99
WATER FOR IRRIGATION,STERILE 99
WERA 90
WESTHROID 92
WYMZYA FE 90
XX-VIATE 74
XALKORI 37
XARELTO 51
XENAZINE 65
XIFAXAN 17
XOLAIR 110
XTANDI 32
XYNTHA 54
XYNTHA SOLOFUSE 54
XYREM 111
ZZAFIRLUKAST 105
ZALEPLON 111
ZAMICET 12
ZANAMIVIR 46
ZANOSAR 32
ZARAH 90
ZAVESCA 75
ZEBUTAL 65
ZELBORAF 37
ZEMAIRA 110
ZENCHENT 90
ZENCHENT FE 90
ZENCIA 74
ZEOSA 90
ZETIA 62
ZEVALIN 38
ZIAGEN 45
ZIDOVUDINE 45
ZINC CHLORIDE 117
ZINC SULFATE 117
ZINC SULFATE HEPTAHYDRATE/CUSO4 P-
HYD/MANGANESE/CHROMIUM/SE 115
ZINC SULFATE/CUPRIC SULFATE/MANGANESE
SULF/CHROMIC CHLORIDE 115
ZIPRASIDONE HCL 42
ZIPRASIDONE MESYLATE 41
ZOLINZA 35
ZOLMITRIPTAN 30
ZOLPIDEM TARTRATE 111
ZOMIG 30
ZONISAMIDE 22
ZONTIVITY 54
ZORTRESS 95
ZOSTAVAX 96
ZOSTER VACCINE LIVE/PF 96
ZOVIA 1-35E 90
ZOVIA 1-50E 90
ZOVIRAX 47
ZYDELIG 37
ZYKADIA 37
ZYTIGA 32
ZYVOX 17
PAGE 153 LAST UPDATED 02/2016